Exploring Food Addiction

David Condos: Hi, guys. Welcome to another episode of Recovery Unscripted. I’m David Condos and this podcast is powered by Foundations Recovery Network. On today’s show, I’m joined by Dr. Julie Friedman, a health psychologist in the specialties of binge eating disorder, night eating syndrome and Cognitive Behavioral Therapy. In addition to leading the binge eating treatment program at Eating Recovery Center in Chicago, she also serves as a professor at the Northwestern University school of medicine.

She sat down with me at the Moments of Change conference in Florida to explore the intersection of food, mental health, substance use and healing. Now, here’s Julie. I’m here with Julie Friedman. Thank you for being with us today.

Julie Friedman: Thanks for having me.

David Condos: Good to have you here. First, let’s have you tell us a little bit about your own personal journey and how you started serving in this field?

Julie Friedman: I was coming from an academic medicine background. I was at a local academic medical center. I was in an obesity medicine clinical practice. If you were of a certain BMI, you were automatically referred there. We would do any kind of care that a patient needed, whether it was exercised physiology, dietary, psychology- obviously, my background- and/or medical. I was doing largely a lot of health psychology. Working with people on their sleep. Working with people with regards to stress management, things like that. We started to get more and more patients with binge eating.

Out of control eating, feeling as if they were addicted to food. It became so overwhelming in terms of the demand for that service and the supply. We had a small department. I contacted our local eating disorder facility in Chicago, Eating Recovery Center of Illinois and I said, “I have all of these people that I can send you, but you don’t have a binge eating program.” She said, “What would you need to feel comfortable referring here?” I started to outline our programmer or my dream program. I had a job offer, I think, within two hours after launch.

David Condos: Wow.

Julie Friedman: I came out of academia into the eating disorder treatment’s phase and we designed, as I said, the program three years ago, launched it initially in Chicago. We started with an intensive outpatient program that grew. We launched residential and we’re actually opening a larger residential facility. That will be 30 beds just for the loss of control eating disorder patients.

David Condos: Did you start out in academia? You said, psychology is your background.

Julie Friedman: I got my PhD in clinical psychology and I originally started actually as a sleep psychologist. Again, the majority of the patients that were coming through were higher weight. Really, really struggling with the number of different issues from a psychiatric or psychological standpoint. All that we were offering them was basically to tell them to lose weight.

It just felt like we have to offer more to these people and it felt like such general weight bias in our healthcare system that all of your questions will be answered when you lose weight. It really was inadequate treatment of the patient. It just felt we’re calling obesity a medical disease which is certainly is, but we’re not treating it like one. We’re treating it like a personal failing.

David Condos: Like substance use and mental health and all that?

Julie Friedman: Actually, I see a lot of parallels between substance use disorder treatment and treatment for these patients in terms of it gone being marginalized in underserved population and this implication that if they just buckle down and showed more will power and showed more discipline, they would get better and that’s not the case. There are strong medical and biological components to their disease just like in substance use disorders.

David Condos: Here at the conference, you just gave a presentation discussing the validity of food addiction and the treatment of binge eating disorder. I’m guessing there’s a lot of skepticism about that. Could you start by saying what would you say to someone who questions whether food addiction is a real thing?

Julie Friedman: It’s really still in its infancy, right? We don’t have good human studies to suggest that human beings can be addicted and have traditional signs with withdrawal and tolerance and cravings and urges to use despite negative consequences. The way we would talk about substance use, we don’t have good evidence to suggest that humans can be addicted to a specific nutrient. When you look at the research, it’s very much wrote in vast, where if you give rats unlimited access to sugar-sweetened water, they keep going back for more.

In humans, what we see is that yes, the same reward pathways or implicated certainly. Just like in substance use disorder we see less dopamine receptors so, less reward in the reward centers and less activity or activation in the inhibitory control centers. I need more and more of something to get reward and then, once I start engaging in the behavior, is very difficult for me to stop.

David Condos: It’s following a similar biological pattern?

Julie Friedman: Exactly. Where it is different, is that we know that chronic substance use will really alter the central nervous system and causing changes in the brain. We don’t have good evidence that food can do that. We have good evidence that food activates the same channels but we don’t have evidence that consumption of food really changes those pathways. We do have evidence, however, that consumption or over consumption of highly palatable and highly processed foods does start to cause some drop out of the neurons that regulate appetite.

People who have a high consumption of these foods particularly in binge eating, night eating, these loss-control eating disorders then, the neurons that inhibit appetite or help the patient feel satiated, start to die out. It’s a lesser reward system issue in the way that substance use is and more of a hunger and satiety mechanism issue that gets disrupted when somebody has the constant inflammatory stress of binging. Most people who describe a food addiction don’t describe pouring salt in their mouths. They describe going for potato chips which are high fat and salty.

Again, this idea of the compulsion towards highly processed, highly palatable foods because it feels good to eat them. Then, when you eat them, it stops the production of stress hormones in your body and stops the wanting of them. It’s a very reinforcing behavior. Do we have evidence that it’s addictive? Not yet. This is really a field that’s in its infancy right now.

David Condos: I guess, is it too early to have a definition or how would you define food addiction in your work?

Julie Friedman: There’s definitely a definition. There’s scale, that’s the gold standard, the most well-established measure food addiction is the Yale Food Addiction Scale. They define food addiction as a clinically significant physical or psychological dependents on certain nutrients or foods. There was a new YFAS or Yale Food Addiction Scale released with the advent of DSM-5 because substance use disorder changed. There were some changes to that diagnosis so, the YFAS changed to basically mirror the substance use disorder criteria.

Now, we really look at how can food parallel what some of those cravings, withdrawal tolerance, continuing to use even though there are negative consequences.

David Condos: A lot of these signs and symptoms are pretty similar?

Julie Friedman: Exactly. That’s what the YFAS was meant to do, was really apply it towards binge eating or out of control eating just as we did with substance use disorder. I think, the problem is that there’s a lot of overlap, really substantial overlap between binge eating disorder and food addiction. It begs the question, are we measuring a distinct entity or are we really measuring a more chronic, more severe, more treatment-resistant version of binge eating disorder? The evidence really suggests that we’re measuring severity of psychopathology and obesity severity as well because food addiction is much more prevalent, four to five times as prevalent in higher weight populations. It seems to be this proxy for psychopathology in addition to obesity severity.

David Condos: It’s a manifestation or–

Julie Friedman: Yes, I would say there’s an additive effect where you have a binge eating disorder that’s fairly clearly defined in our diagnostic manual and then, you have this concept of food addiction which really is a more severe variant of binge eating plus other markers. We know trauma severity. For instance, if you have an extensive trauma history, your chances of being diagnose with food addiction go up. Again, the higher weight you are, there’s a positive correlation with YFAS course. The more you weight, the more likely you are to meet criteria for this. That’s where there are some measurement issues in that A, it’s a self-report measure, but B, it does seem to be tapping other things other than this distinct entity from binge eating disorder. I think it needs a little bit of refinement.

David Condos: Like you said, it’s all new in its infancy.

Julie Friedman: In its infancy, yes.

David Condos: Seeing it develop in real time.

Julie Friedman: Yes.

David Condos: When a lot of people think of eating disorders, they probably think of anorexia or bulimia like you said earlier, but I know- just from the little bit of research I did for this interview- that there are a lot of other conditions that people probably don’t know as much about. One that you’ve mentioned a couple times, there’s years binge eating disorder is one of your specialties, it sounds like. Could you describe what that entails and what you do with it?

Julie Friedman: Binging and the way we define a binge eating episode would be eating more in a discrete period of time then, most people would eat in the same time period and under similar circumstances and feeling a loss of control while you’re eating like you can’t stop yourself from eating. It’s important to know, I think everybody binges. Binging is part of the normal continual of eating behavior, but what differentiates normative binging from a binge eating disorder would be binging one time a week for duration of three months or more. We really took the model or the paradigm from substance use disorder.

Can we get somebody out of their environment? Interrupt the behavior and treat them really intensively, give them a ton of skills and then send them back to their home environment with good aftercare planning. That’s really the approach we took for binge eating disorder.

David Condos: Then night eating disorder was another one. I saw it mentioned, I’m not familiar with. Could you tell us a bit about that?

Julie Friedman: Sure. Night eating syndrome involves, essentially, a circadian delay in food intake. It would be a patient, essentially, waiting until noon or later to eat, four or more mornings per week or skipping breakfast entirely. Eating 25% or more of their total daily calories between dinner and bedtime, after dinner. Then, having some form of sleep disturbance, whether they have difficulty falling asleep or they have difficulty staying asleep. These patients can wake up in the middle of the night, eating, go back to bed, but it’s not a necessary criteria.

I think it goes undiagnosed and it’s really significant in terms of disrupting a patient’s life. You’re not eating properly during the day. It makes it hard to function during the day, but most importantly, they become so sleep-deprived that that impairs their daytime functioning as well. It’s associated with some mood changes, depressive symptoms and increase in nocturnal anxiety, things like that.

David Condos: What are some of the most common causes that you see? I was looking at the website, it had biological, environmental, cultural. What are some of the causes you see for these different conditions we’ve been talking about?

Julie Friedman: I would say that eating disorders are about 80% genetic and neurobiological.

David Condos: Really? Wow.

Julie Friedman: Absolutely. I think you’ve got the genetic predisposition and yes, there are certain environmental factors that can bring them out. For instance, perfectionist to temperament, but in general these are really neurobiologically-based disorders. To give you an example, leptin. Leptin is satiety hormone, it tells us to stop eating, store energy, you’re full. We know with anorexia nervosa, these patients have low-levels of leptin which means that they have an increased sensitivity to feeling full.
Now, with binge eating disorder, we see the opposite. They have high-levels of leptin so, they’ve all this leptin floating around and their unable to use it. We know that they happen an insensitivity to feeling full.

David Condos: Just want to make sure I understand so that the leptin, it’s naturally created in their body and they get a tolerance to it to where they don’t feel full like someone who doesn’t have that would feel full?

Julie Friedman: Exactly. Their brains essentially, leptin receptors are unable to use it. A lot of this is brain-based and a lot of it is a dysfunction in the way that the brain and the gut communicate to one another. There are a lot of neurobiological factors, dopamine, serotonin. There are a lot of things that have been implicated. I will say that the main psychological or behavioral variable that has been implicated is avoidance of feeling bad, feeling uncomfortable, using behavior to make that go away very quickly. We call that negative urgency. That’s certainly related to eating disorder behaviors, but it doesn’t cause eating disorder behaviors. It’s a contributor.

David Condos: Related to that, you mentioned earlier that you have a mood and anxiety specific program. Could you say a little bit about how those interact with the eating disorders? What role that can play?

Julie Friedman: Sure. 85% of patients with eating disorders will also make criteria for a comorbid mood or anxiety disorder. It’s very, very common. We don’t know what comes first, the chicken or the egg. Did somebody start depressed and then develop an eating disorder, vice versa, we don’t know, but certainly, in all of our eating disorder programs, we have to do good mood and anxiety work or we’re setting our patients up to relapse. Our mood and anxiety program, we were getting all these calls and people were asking, “I don’t have an eating disorder, but can I come into your programming?”

There was this need for it. The mood and anxiety program was born, that programming is for patients who don’t have any eating disorder pathology. If you have, let’s say, anxiety, generalized anxiety disorder and binge eating disorder, you would go into the binge eating disorder program, we would treat both. For patients who really want this kind of treatment and didn’t have any eating disorder symptoms, we wanted to get them something and offer some treatment for them as well.

David Condos: Then, I also saw in your bio that Cognitive Behavioral Therapy is one of your specialties. How have you seen CBT help those with eating disorders? I know that something that we see a lot with addictions so I’m interested to hear that.

Julie Friedman: CBT is the most well-established psychological treatment for binge eating disorder. All of the studies really bear that out. Part of the rationale for that or part of the reason why we think that is, is because in order to arrest some of these behaviors, you’ve got to work on the behaviors directly. A lot of patients come in and they feel like, “If I just learn why I have an eating disorder, it’ll just magically make these behaviors go away.” We know that’s not the case.

You can have great insight, but if you aren’t taught to do something different, particularly in times in which you’re vulnerable to cravings and urges and things like that, you’re not going to be very successful in managing your disorder. I think the present focus of CBT, the behavioral focus of CBT certainly that less intervening with your behaviors first because it’s what we have them most control over. We have a less control over how you feel and so, we really work with patients to abandon some of that control. Let’s accept how you feel and move on because your feelings are your feelings and they’re biologically determined. We’re going to help you engage in different behaviors when you feel these feelings, but at the end of the day, if you don’t behave differently, life isn’t going to look very different for you.

David Condos: Just like with addiction, you got to find the different way to cope with what you have going on.

Julie Friedman: Absolutely. Again, I’m not saying that insight oriented therapies aren’t great because it’s amazing to know why you do what you’re doing. It really is, it’s great. It just doesn’t help somebody recover from an eating disorder or from a substance use disorder for that matter. They really need a whole new set of skills, coping skills and behavioral interventions.

David Condos: Moving to the next thing. There is a lot of similarities, like we’ve said, but something that’s different from substance use is that food is all around us. It’s necessary part of life. I guess, how do you help people transition back into life when they’re going to be around food all the time, they have to eat food. Abstinence isn’t really an option for them.

Julie Friedman: Exactly. I think, a lot of planning a lot of prep in the sense that yes, you have to eat, but you can be mindful about the way that you incorporate triggering foods into your diet.

David Condos: It’s more about the mental side of how you view food?

Julie Friedman: Yes. I think planning ahead for it. The worst thing that somebody who has an eating disorder can do is eat something that is triggering to them impulsively. The idea of, “Okay, you’re not going to be abstinent from food. You’re not going to be abstinent from your trigger foods, but maybe your abstinence looks like you don’t eat a trigger food without planning it 24 hours in advance and early recovery.” Not going too long without eating. Having them plan ahead, have them carry food with them. How do we get some movement into our life every day because movement will help decrease some of the urges to binge. Things like that.

David Condos: Let’s wrap up with this final question. You’ve given a lot of your life and your time and yourself to this mission. Like you said, you were at the university level for a while and now doing what you’re doing with ERC. Could we wrap up by having you sum up why helping others find recovery from eating disorders is so important to you?

Julie Friedman: I think that this is something that patients are really, really struggling with. They’re struggling physically, they’re struggling emotionally and they’re struggling with this public perception that this is something that is in their control entirely and that can be easily fixed if they show more discipline and willpower. I think to me, the biggest thing is helping a population that’s been largely stigmatized. That’s important to me, how can we take the blame away from the patient and give them the resources they need to find recovery?

We’ve done it with substance use disorders. We really have where people recognize, “Okay, if my spouse is drinking every night, we need to send them to a place that will help contain the behavior and then, get him back home.” With eating disordered behavior, that’s not as obvious. Patients will come in and they are so sick medically, emotionally, psychiatrically because they’ve gone so long without treatment because nobody identified their problem and when they did identify the problem, they didn’t treat effectively or efficiently.

I think that’s the biggest sort of take home for me is, how can we help a population that so largely pleasant and sweet and wanting help and motivated and really make eating disorder treatment accessible for not just wealthy patients. I don’t want care to be just for people who can afford it. I want people to be able to use their mental health benefits for care. That mission really appeals to me in terms of helping people live better lives and lives outside of their eating disorder.

David Condos: All right, thank you for your time. It’s been a pleasure having you on, Julie.

Julie Friedman: Awesome, thanks so much.

David Condos: Thanks again, to Dr. Friedman for joining us. Now, I’ll close the show by featuring another story from the Heroes in Recovery community as part of our ongoing series called ”Hero of the Week.” Today’s story comes from Megan C., who shared it on heroesinrecovery.com, a grassroots movement where over fifteen hundred people have contributed their stories. At the age of fourteen, making began using food to cope with their social anxiety and depression. The more her parents expressed concern, the more she hid her increasingly destructive eating habits.

By the age of 25, she realized she had formed an addiction to food. After failed attempts to conquer the problem with diets and gym memberships, Megan’s deteriorating health issues forced her to realize she didn’t want to live like that anymore. She turned her feelings of sadness and hopelessness into motivation and now enjoys a healthy relationship with food bolstered by exercise, writing, meditation, therapy and online support groups. As Megan says in her story, “No matter how low you feel now, it can get better, one slip, one binge, one cookie, does not make you a bad person or a failure. It means you just wipe it away and keep on going.”

Thank you for sharing that, Megan, and for helping to break the stigma around addiction and mental health issues. If you’d like to read Megan’s full story or share your own, visit heroesinrecovery.com.

This has been the Recovery Unscripted podcast. Today we’ve heard from Dr. Julie Friedman of Eating Recovery Center. For more about their work, visit eatingrecoverycenter.com. Thank you for listening. Please take a few seconds to leave us a rating on your podcast app and subscribe so you won’t miss any of our new episodes. See you next time.