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Clinical Considerations of Ultra-processed Food Addiction Across Weight Classes: an Eating Disorder Treatment and Care Perspective

Clinical Considerations of Ultra-processed Food Addiction Across Weight Classes: an Eating... Purpose of Review To examine the prevalence rates of ultra-processed food addiction across different weight classes and offer guidelines for diagnosis and treatment. Clinicians are provided with practical considerations in the assessment of ultra- processed food addiction beyond the use of validated instruments. Recent Findings The weighted mean prevalence of ultra-processed food addiction is approximately 20% worldwide and var- ies widely based on the sample. At first glance, there appears a linear relationship between ultra-processed food addiction and BMI class. Further investigation indicates a J-shaped curve with heightened prevalence among the underweight. These findings highlight the need to assess for additional factors that may increase objective or subjective food addiction symptoms including eating disorders, dietary restraint, and other mental health diagnoses. Summary While clinical considerations across different weight classes vary, overemphasis on weight status may detract from the clinical utility of the ultra-processed food addiction construct. Considering weight status in conjunction with other psychiatric symptoms helps to better understand the various biopsychosocial mechanisms that influence eating behavior and can inform individualized treatment strategies. Keywords Food addiction · BMI · Eating disorders · Dietary restraint · Weight stigma · Trauma Introduction The purpose of this review is to describe the reported prevalence rates of FA across different weight classes and to The phenomenon of food addiction (FA) has been mentioned provide clinical guidelines for diagnosis and treatment, with in over 2,500 published articles to date [1 ]. Most research particular emphasis on the underweight category. The aim studies have operationalized FA using the Yale Food Addic- is to offer clinicians practical guidelines in the assessment tion Scale (YFAS) [2] and more recently YFAS 2.0 [3] based and treatment of FA beyond the use of validated instruments. on DSM-5 criteria for substance use disorders (SUDs). FA There is growing trend toward use of the term “ultra- can be understood as hedonic eating after homeostatic require- processed food addiction” (UPFA) emphasizing noteworthy ments have been met [4, 5] with continued consumption differences from minimally processed foods in their addic- despite negative consequences [6]. Paradoxically, FA symp- tive potential [8–12]. Given that the YFAS specifically asks toms have been reported among underweight individuals who about the consumption of ultra-processed foods with added may not be meeting their energy needs [7 ], necessitating a sugars, salts, and fats, the terms FA and UPFA have been closer examination of the FA construct through the lens of used interchangeably. The UPFA nomenclature may advance eating disorder (ED) psychopathology and related symptoms. the utility and specificity of the FA construct, given that nearly 60% of the calories consumed in the USA come from ultra-processed foods [13]. Henceforth, the term UPFA will This article is part of Topical Collection on Food Addiction be used to describe the phenomenon of food addiction. While clinical considerations across different weight * David Wiss classes may vary, this review argues that overemphasis on davidawiss@nutritioninrecovery.com weight status may detract from the clinical utility of the Community Health Sciences Department, Fielding School UPFA construct. Weight (and BMI) is often analyzed as of Public Health, University of California, Los Angeles, 650 an outcome which is influenced by an array of biological, Young Drive South, Los Angeles, CA 90095, USA Vol.:(0123456789) 1 3 Current Addiction Reports psychological, social, and behavioral causes whereas addic- sequence of disorder onset. This limitation may make the tions are defined (and diagnosed) solely by behavioral cri- interpretation of rising UPFA prevalence “noisy” because teria. Thus, consideration of UPFA as a behavioral health many ED symptoms can increase YFAS scores [33 ]. Simi- disorder (rather than weight disorder) may provide more larly, UPFA can precede ED behaviors, generating a chicken insight into clinical treatment strategies. versus egg conundrum for researchers and clinicians. Several studies have failed to show significant correla- tions between UPFA and BMI [14–18]; therefore, efforts to address UPFA clinically should not be synonymous Ultra‑processed Food Addiction and Eating with weight loss. Rather, UPFA has been associated with Disorders reduced quality of life [19] through mechanisms such as emotion dysregulation [20–22] which can be targeted. Fur- Clinical samples (such as those with EDs) have higher UPFA thermore, UPFA has been associated with altered psychoso- prevalence than community-based or representative samples cial functioning more than with metabolic parameters [18]. [34]. Specifically, individuals with bulimia nervosa (BN) Meanwhile, considering one’s weight status in the clinical have the highest prevalence of UPFA (48–95%), followed evaluation of UPFA might be useful to better understand the by binge eating disorder (BED; 55–80%), and anorexia ner- • • various biopsychosocial mechanisms that influence eating vosa (AN; 44–70%) [1 , 35 , 36]. Most studies investigating behavior (including the subjective experience of it). the association between AN and UPFA found that UPFA symptoms are higher among those with AN binge-purge type (AN-BP) compared to the restrictive subtype (AN-R) [37, Ultra‑processed Food Addiction Prevalence 38, 39 , 40]. An understanding of the heterogeneity in UPFA presenta- The most recent systematic review and meta-analysis of 272 tions necessitates assessment for ED psychopathology, par- studies using the YFAS, YFAS 2.0, and derivative scales ticularly the role of restrained eating and other compensatory reported a weighted mean prevalence of UPFA diagnoses behaviors as a cause and/or consequence of UPFA symptoms • • at 20% worldwide (95% CI: 18–21%) [1 ]. The prevalence [33 ]. The symptoms of UPFA in under-to-normal weight of UPFA varies widely based on the sample under study. ranges may represent individuals exhibiting compensatory Clinical samples have higher prevalence than non-clinical behaviors (e.g., purging in BN or AN-BP, or over-exercis- samples [1 ]. A nationally representative sample from the ing) which keeps their BMI stable (or decreasing) despite USA reported UPFA prevalence at 15% [7 ], which closely the presence of addiction-like eating (e.g., bingeing, loss mirrors prevalence rates of other substance-related behaviors of control) commonly associated with weight gain [41 ]. in the USA [23]. While the prevalence of UPFA is generally It has been suggested that weight control behavior in indi- higher in women than men [24–26], these findings are not viduals with BN may dampen reported associations between consistent [7 ]. addiction-like eating and BMI [42, 43]. UPFA prevalence estimates are higher in adults com- There is a growing trend toward viewing UPFA and EDs pared to children and adolescents (15%; 95% CI: 11–19%) from a transdiagnostic perspective [44–46] particularly in [27], suggesting that symptoms develop over time, much relation to food cravings [47]. The clinical considerations like other addictions. Increased exposure to ultra-processed discussed herein are designed to improve our understand- foods may contribute to early recruitment of brain regions ing of the UPFA construct in individuals with and without associated with food consumption and choice [9]. A blunted EDs. Equally important, UPFA is frequently seen in subjects reward experience might increase overconsumption behav- without EDs (or other psychiatric disorders) in the general ior in attempt to reattain the expected reward [28]. Reward- population, which suggests that UPFA is a distinct entity related susceptibility to addictive processes may also be from EDs and other psychiatric illness [48]. exacerbated by various forms of stress, trauma, and adver- sity often associated with low socioeconomic status and unhealthful food environments [29]. Ultra‑processed Food Addiction and Body Recent studies have shown that the COVID-19 pandemic Mass Index increased the incidence rate of UPFA [30] and associated weight gain from eating behavior attributable to circum- Without a nuanced understanding of how UPFA symptoms stances such as isolation [31]. It has also been documented present clinically in the under and normal weight catego- that COVID-19 led to a surge in EDs [32]. Directionality ries, a linear relationship between UPFA and BMI might between UPFA and ED symptoms during the pandemic (and be assumed. Figure 1 is adapted from the recent Praxedes before) remains unclear. A major shortcoming in research et al. meta-analysis [1 ] and represents the broadest pos- linking UPFA to EDs is a failure to disentangle the temporal sible relationship between UPFA and BMI. The pooled 1 3 Current Addiction Reports Fig. 1 The broadest view of the relationship between BMI and ultra- Fig. 2 A closer view of the J-shaped relationship between BMI and processed food addiction prevalence from meta-analytic data reported ultra-processed food addiction prevalence from a nationally repre- • • by Praxedes et al. [1 ] sentative German sample reported by Hauck et al. [49 ] prevalence among individuals considered normal weight a homeostatic drive for food from an undernourished state was 17% (95% CI: 16–19%); among overweight was 24% [7 ]. (95% CI: 19–29%); and among those considered obese was In the next section, the literature exploring the non- 28% (95% CI: 24–32%). Not enough UPFA studies among linear relationship between UPFA and BMI categories are the underweight class were available for pooled analysis. reviewed. Furthermore, mental health considerations are At first glance, the relationship between UPFA and BMI included to assist in developing treatment strategies when appears linear. positive UPFA screens occur in different BMI categories. Other investigations of UPFA prevalence including indi- Recommendations prioritize ED recovery and are designed viduals with EDs generates J-shaped curves, with the under- to reflect weight-inclusive approaches to managing health weight category demonstrating sharply higher UPFA preva- [55 ]. An argument will be made that UPFA appears primar- • • • lence (12–46%) [7 , 41 , 49 ]. A representative USA sample ily related to eating pathology and only secondarily related indicated that the prevalence of UPFA is paradoxically high- to body weight [52]. est in the underweight category (46%) [7 ]. A representative German sample indicated UPFA prevalence among under- weight (15%) as higher than class I obesity (12%) but lower Ultra‑processed Food Addiction and Dietary than class II (21%) [49 ]. Not surprisingly, prevalence rates Restraint differ widely according to sample demographics. It is also possible that food insecurity may increase UPFA symptoms, This section reviews often overlooked clinical symptoms which may be relevant across BMI classes [50, 51]. Key among individuals with UPFA who also exhibit high levels findings from several recent studies show that obesity cannot of dietary restraint (DR). While binge eating and UPFA are be explained solely by UPFA [52–54]. not synonymous, research linking DR to binge eating will be Data from the German sample [49 ] are presented for used to conceptualize relationships between UPFA and DR. conceptual purposes in Fig. 2. The prevalence rates in Fig. 2 It is also plausible that dieters may not subjectively binge but are not intended for direct comparison to the meta-analytic rather display other characteristics of addiction-like eating findings in Fig.  1, but rather to illustrate how a more fine- such as social impairment, avoidance, and emotional dis- grained analysis of BMI reveals information that could be tress, all of which could increase UPFA severity indicators. overlooked. A non-linear relationship suggests that UPFA Published data linking UPFA and DR are mixed. Cross- is not the only contributor to weight gain and may reflect a sectional data have linked UPFA scores with higher levels distinct phenotype of problematic eating that is not synony- of DR [56] whereas the validation studies of the YFAS and mous with obesity [49 ]. It is also possible that self-reported YFAS 2.0 showed no significant correlations between UPFA UPFA symptoms in the lowest weight class are relics of diet- and DR [3, 57]. Among adolescents in a weight loss pro- ing and caloric deprivation that mimic behavioral indicators gram, UPFA was not related to eating restraint [58]. Other of addiction. Examples include eating more than intended investigations of adolescents have shown positive correla- due to a violation of dietary rules, or cravings that reflect tions between UPFA and DR [59]. Less is known about the 1 3 Current Addiction Reports temporal relationship between DR and UPFA symptoms, may experience varying effects on their body weight, par - requiring longitudinal investigations in samples with and tially depending on whether the restraint is part of a recovery without current (or prior) EDs. plan, mistargeted (i.e., excessive), inadequately supported, While it is well known that efforts to restrain eating often or part of a restrictive ED [29], which can be driven by body contribute to binge eating, other models suggest that UPFA dissatisfaction. leads to weight gain and then progress to DR [60]. This pat- tern is frequently observed among other addictive disorders. For example, repeated alcohol exposure can lead to problem- Ultra‑processed Food Addiction and Body atic use which could in turn lead a person to restrict their Image Disturbance alcohol use to mitigate these problems. The return to alco- hol (i.e., relapse) closely resembles the way some return to Body image disturbances are known correlates of DR and highly palatable foods following a period of abstinence [46]. EDs and are related to quality-of-life measures [77]. Sus- Early research among women with BN revealed that the ceptibility to attentional biases toward appearance-related first binge preceded diet onset in 9–37% of cases [61, 62]. information might be one vulnerability factor in the pro- In a cohort study of young women dieting, only 3.5% devel- longed persistence of body image disturbances in daily life oped an ED of clinical severity during the 2-year follow-up [78]. Cohort data found that the adolescent drive for thinness [63]. A recent review found no experimental support for the continues into adulthood and may predict compulsive eating DR theories of EDs, suggesting that DR may activate vul- behavior (reward-based eating) and greater BMI independ- nerability factors leading to ED symptoms but only among ent of childhood weight [79]. Body image disturbance may those already vulnerable [64]. As previously stated, DR persist over the life course and should be evaluated when may be a consequence of weight gain and the perception of treating all forms of disordered eating behavior. overeating. Therefore, divergent models are needed to bet- Body image disturbance has been independently associ- ter understand directionality between UPFA and DR [60]. ated with UPFA symptoms, suggesting that it may be one Food cravings have been linked to dieting [65], and important factor in the development and/or maintenance of efforts to restrain eating predicted future overeating during UPFA [80]. While it is likely to be a consequence of UPFA, COVID-19 through negative emotions [66]. Data on twins assessment of body image through validated instruments has shown that frequent attempts to lose weight reflect future or by clinical evaluation may be important for developing susceptibility to weight gain [67], but the precise mecha- treatment interventions. For example, if body dissatisfaction nisms remain unclear. A randomized controlled trial using drives DR which in turn contributes to UPFA symptoms, internet- and app-based intervention demonstrated that tar- targeting body image disturbances might reduce dieting and geting DR led to greater reductions in binge-eating eating improve addiction-like eating [81]. While the number of episodes compared with controls [68]. Taken together, it young people with elevated BMIs continues to grow, so has appears that DR may be one contributor to UPFA symptoms the percentage of youths experiencing body dissatisfaction such as binge eating and therefore might be a useful target and weight stigma [82], necessitating incorporation of this for clinical interventions among individuals meeting criteria discourse into public health campaigns. for UPFA, especially those with comorbid EDs. Other research suggests food reward tends to decrease during weight management interventions [69]. A study Weight Stigma using caloric restriction for at least 12 weeks reduced food cravings, supporting a deconditioning model [70]. Various Recent conceptual models have suggested that the expe- dimensions of food cravings are differentially related to out- rience of weight stigma may drive DR and contribute to comes in dieting [65]. Short-term selective food deprivation UPFA symptoms [29]. Among adolescents, UPFA signifi- increases cravings for avoided foods while long-term energy cantly mediated the association between weight-related restriction results in craving reductions, indicating a reduc- self-stigma and binge eating [83]. In a longitudinal study of tion of previously acquired conditioned responses [71]. young adults, fear of being stigmatized predicted worsening In summary, DR has been viewed as both the problem UPFA symptoms over time [84]. These studies suggest that and the solution to rising BMIs [72]. Efforts to lose weight the experience of weight stigma contributes to UPFA among or restrict food can make eating pathology worse [73–75]. some individuals. Other research suggests that understand- It is unclear whether efforts to eat differently (emphasizing ing UPFA broadly reduces weight stigma by minimizing quality rather than quantity) should be classified as disor - the blame narrative associated with “personal responsibil- dered behavior [29] including Orthorexia Nervosa [76], but ity” [85, 86]. Several authors have proposed that targeting likely depends on an individual’s psychiatric profile [33 ]. weight stigma at the societal level should be a public health Individuals who meet criteria for UPFA and engage in DR goal [87]. Targeting the internalization of weight bias can 1 3 Current Addiction Reports be beneficial among those with UPFA, regardless of their impulsive behavior when treating UPFA. A family history of weight status. SUD should be considered in the assessment [46]. Anti-obesity messaging may put vulnerable individuals In patients with both UPFA and SUD, targeted treatments at risk for EDs [88]; a highly undesirable outcome. Mean- that reduce impulsivity and increase self-directedness may while, evidence-based treatments for obesity can reduce improve treatment outcomes [97]. While this may be dif- disordered eating behaviors without increasing internal- ficult, evidence of UPFA channeled by trait levels of impul- ized weight stigma [89]. Divergent views in the field may sivity may help explain why addictive-like behaviors can arise from a failure to separate advocacy from evidence, be recalcitrant to change [21]. The associations between as well as training/discipline bias. Efforts to find a com- UPFA and impulsivity have been shown to associate with mon ground between the prevention of obesity and EDs are more frequent weight fluctuations and higher BMIs [98]. greatly needed [64]. But given that UPFA is not synonymous This information may be helpful to clinicians working with with obesity, it is imperative that researchers and clinicians disordered eating by reducing stigma surrounding eating understand the potential relationship between weight stigma pathology, advancing trauma-informed care for addictive and UPFA independent of BMI. disorders [99]. Trauma and Post‑traumatic Stress Disorder (PTSD) Ultra‑processed Food Addiction and Other Trauma, particularly early in life, has been associated Mental Health Disorders with increased BMI over the lifespan and UPFA may be one mediating mechanism [43, 100]. The risk for UPFA A detailed discussion of the associations between relevant increases following exposure to early life psychological, mental disorders and UPFA is beyond the scope of this sexual, and physical abuse [19, 101]. In fact, all forms of review. Nevertheless, some of the associations between trauma increase risk for UPFA, likely driven by PTSD symp- select mental health disorders and UPFA will be summa- toms [102]. The association between early life adversity and rized to aid clinicians treating UPFA. An 8-step assessment UPFA might be the result of multiple pathways of biological process to discern UPFA from DR using psychiatric symp- embedding [43], such as reward processing [103, 104] which toms has recently been published [33 ]. This process has not can heighten risk for SUDs [105] and impulsivity [106]. been validated but may be useful as a roadmap for conceptu- Associations between early life trauma and EDs are well- alizing UPFA treatment in the context of EDs (emphasizing described [107, 108] but efforts to investigate the role of DR as a proxy for restrictive behaviors associated with EDs). UPFA as a mediator, moderator, or outcome are limited. UPFA, as well as emotional eating, have been shown to Substance Use Disorders mediate the relationship between psychological distress and BMI [109]. Based on the available evidence, it appears Research linking UPFA to SUDs are mixed. There is some important to look for signs of trauma and PTSD when evidence of elevated UPFA prevalence in those with SUDs designing interventions for UPFA. Considerations include [90] as well as cross-addiction between food and substances the mechanisms of biological embedding that may impact of abuse [91] but these associations were not statistically eating behavior as well as the possibility that some nutrition significant in a recent meta-analysis [92]. Nevertheless, interventions (e.g., excessive DR) can be triggering for some UPFA has been associated with a family history of addic- individuals, particularly those with food-related trauma (e.g., tion [20] and brain reward dysfunction [11]. Based on clini- parents who imposed dieting and body shaming [110]). cal experience, many individuals with severe UPFA do not cross-addict into other substances, partly because highly Depressive Symptoms palatable foods are always available and therefore remain the substance of choice (or no choice). In a systematic review and meta-analysis, the weighted Impulsivity strongly correlates with problematic sub- mean correlation between UPFA and depression was 0.46 stance use [93, 94] and is consistently associated with UPFA (95% CI: 0.36–0.55) [92]. This relationship is bidirectional [95]. While it has been suggested that a history of SUD and may be important for psychoeducation in those with might help with clinical implications of UPFA [33 , 46], UPFA. Ultra-processed food consumption increases the risk impulsivity might be a more informative concept. Higher of developing depression [111, 112] while “Mediterranean- distress-driven impulsivity has been associated with more Style” eating patterns have been associated with reductions addiction-like eating behaviors among participants clas- in these symptoms [113]. Thus, when depressive symptoms sified as cognitively inflexible [96]. Thus, the presence of are present, patients with UPFA should be counseled to eat any current or previous SUD may be a proxy measure for in ways known to reduce these symptoms [114]. 1 3 Current Addiction Reports There is a U-shaped curve between BMI and depression, 2) Assess for the presence of AN, particularly AN-BP. If where the highest rates occur in underweight and obese cate- present, the current evidence-based treatment includes gories [115]. It is plausible that associations between under- weight restoration [120]. Obsessive–compulsive disor- weight and depression stem from undernutrition, although ders and anxiety frequently occur when AN is present this is not well documented. From clinical experience, coun- [121, 122]. In patients with AN-R, a high YFAS score seling efforts focused on mental health outcomes such as often reflects fear of overeating, bingeing, or loss of con- depressive symptoms rather than weight are welcomed by trol rather than the actual behavior [123]. This concept is most patients (once recent data on weight science have been supported by evidence of AN patients reporting greater discussed). UPFA symptomatology while being able to success- fully regulate their food cravings [124]. Recent research has suggested there are two distinct phenotypes among Clinical Considerations of Ultra‑processed those with co-occurring AN and UPFA: (1) restriction Food Addiction Across Weight Classes that drives perceived or actual UPFA symptoms; and (2) genuine UPFA that is premorbid to AN, where a In this final section, clinical considerations for UPFA are heightened reward response to ultra-processed foods broken down by weight classes, with emphasis on the under leads to restriction or fasting [39 ]. If the latter is pre- and normal weight categories. Differentiation by weight sent, nutrition interventions aimed at reduced exposure status does not imply that UPFA treatment should be deter- to ultra-processed foods while simultaneously pursuing mined by BMI alone, but rather that BMI might influence weight restoration may be clinically appropriate. It may intervention priorities. It is important to distinguish UPFA also be useful to discuss the pros and cons of engaging from restrictive EDs before UPFA-related treatment is in a 12-Step program for compulsive eating, as these implemented. groups can be attractive to those feeling misunderstood Recommendations are generated from available evidence by clinicians but can reinforce restrictive ED symptoms and the clinical experience of the author which have not in some cases [125]. been validated. Systematic reviews of interventions for 3) It is important to assess for DR and other compensatory UPFA have recently been published [116, 117]. Ketogenic behaviors (e.g., excessive exercise) in the absence of diets used in the treatment of binge eating and UPFA [118, clinically significant ED that may be driving weight loss. 119] are controversial and are not discussed here but may If these behaviors are driven by body dissatisfaction, have utility in select cases. therapeutic interventions aimed at promoting positive body image can be helpful [126]. When present, it is Underweight important to address restrained eating and the relentless pursuit of thinness as risk factors for EDs and potential The heightened prevalence of UPFA among those in the predictors of compulsive eating and rebound weight gain underweight BMI category and its treatment has not been later in life [79]. Investigating weight history is informa- well described. When other comorbid conditions have been tive to better understand metabolic and psychological identified, it is useful to explore the items on the YFAS concerns associated with weight-cycling [127]. After that specifically contribute to elevated UPFA scores. An weight restoration, the goal is weight stability. Outcomes interview-style assessment is helpful to ascertain if these are improved when a registered dietitian nutritionist spe- individuals engage in objective or subjective overeating [7 ]. cialist is involved [128]. Other questions such as changing social, occupational, or 4) It is important to assess for the presence of current SUD recreational activities, or continuing to eat despite physical which may drive malnutrition [129]. When present, or psychological problems may reflect subjective experi- evidence-informed recommendations should address ences, especially when considering ultra-processed foods the specific substances used [130] while abstinence or that often elicit moral judgments about these foods [34]. harm-reduction strategies are being pursued. The six clinical considerations below are derived from an 5) Determine if trauma symptoms or trauma history is expanded 8-step process designed to help separate overlap- present and provide general psychoeducation that links ping signs and symptoms of UPFA and DR [33 ] but did not adversity to food and body issues as one part of an estab- consider differences across BMI categories. When UPFA is lished evidence-based trauma treatment [131]. Over- detected among the underweight class: looking trauma may contribute to poor treatment out- comes because unresolved adversity may be considered 1) Rule out food insecurity or other forms of socioeco- a fundamental cause of all downstream psychopathology nomic disadvantage or deprivation that might be elevat- [132]. ing UPFA symptoms. 1 3 Current Addiction Reports 6) Evaluate for depressive symptoms and if present, con- tribute to this outcome, aiming to reduce addiction-like sider the possibility that undernutrition, body image eating gradually over time. disturbance, or pathological restrained eating is con- tributing to this outcome and target all three potential Overweight/Obesity vulnerability factors. In some cases, anti-depressant medications may be indicated. All weight categories above normal have been merged to emphasize that UPFA recovery can be pursued independent of weight status. Clinicians and patients may assume that Normal Weight weight loss is the key outcome of UPFA recovery, but this assumption detracts from important quality of life outcomes The normal weight class has the lowest UPFA prevalence, which should be prioritized. The likelihood of transitioning but there are important clinical considerations which aim to from an obese classification to normal weight over a 9-year distinguish contributions from EDs such as BN and BED. period is less than 1% [133]. For this reason, other goals Much like the underweight category, investigating the spe- such as reducing disordered eating, other addictive behav- cific YFAS questions which lead to a positive UPFA screen iors, trauma symptoms, and depressive symptoms should be might help clarify subjective versus objective overeating. prioritized. When patients lose weight during UPFA treat- Once this assessment has been made, continue to the steps ment, it is often the result of better nutrition and lifestyle outlined for the overweight/obese class. Treatment for UPFA habits, as well as improved stress management. One way to in the normal weight class includes: deemphasize weight in UPFA treatment is to avoid weigh- ing people throughout treatment, as well as discourage them 1) Investigate BN and BED and address associated behav- from weighing themselves. iors such as bingeing, purging, and restricting with the If UPFA is detected among the overweight/obese class, goal of reducing or eliminating these behaviors. Absti- the steps outlined for normal weight should be pursued first. nence from purging is an important goal but may take Once these considerations have been made, UPFA may exist time, particularly in outpatient settings. Identifying as a separate entity from an ED or other diagnosis. When “trigger foods” with the goal of abstinence is controver- UPFA has become the primary target for recovery: sial among ED professionals. It can be helpful to deter- mine the order of UPFA or ED manifestation. If the ED 1) Create a meal strategy that is consistent in nutrients with came first, traditional ED treatment which incorporates positive sensory experiences with food. Avoiding hunger these foods might be the safest course. One of the goals and gaps in nutrients are important in creating a consist- of normalizing these foods is to disrupt the cognitive ent (yet varied) experience with food to reduce hedonic distortion of good versus bad foods. If UPFA appeared overeating [134 ]. For example, three meals plus one or first, consider excluding specific foods that contribute two snacks containing all the macronutrients at meals. to bingeing, but only after other clinical considerations Deficiencies in fiber, protein, and fat might contribute to have been identified. hunger which could increase the risk for hedonic eating. 2) Same as #3 for the underweight class. Discussion of Meals and snacks consumed throughout the day should weight stigma in society and internalized weight bias include food that is hot, cold, crunchy, creamy, savory, can be helpful. A common goal is to avoid the relent- and sweet (i.e., fruit). Over-restricting caloric intake is less pursuit of thinness by stressing consumption of an not recommended, as the goal is to reduce symptoms of appropriate amount of food from all macronutrient cat- UPFA [134 ]. Cravings should diminish over time and egories at meals and throughout the day. emphasizing patience is critical. 3) The clinician should assess for comorbidities such as 2) Switching the goal from weight loss to improved mental SUDs which may be contributing to addiction-like eat- health quality of life can reduce the perception of weight ing. If present, use substance-specific protocols [ 130] stigma. Addressing internalized weight bias might while pursuing abstinence or harm-reduction strategies. reduce feelings of stress and adversity that in turn make The temporal sequence between disorders of food and improvements in eating more accessible [29]. Treatment other substances should be investigated. If UPFA symp- professionals should discuss the issue of fat shaming in toms clearly preceded other substance use, this may society [135]. favor moving toward abstinence from addictive foods, 3) Move toward a low glycemic carbohydrate diet (e.g., after other clinical considerations have been made. beans and high-fiber whole grains) given that high gly - 4) Same as #5 for the underweight class. cemic carbohydrates (e.g., refined grains and added 5) Same as #6 for the underweight class with additional sugars) can interact with mesolimbic dopamine systems consideration that excessive reward activation may con- that heighten food cravings and may lead to loss of con- 1 3 Current Addiction Reports trol [45, 136]. Identifying individual trigger foods that for clinically significant EDs among vulnerable groups. In should be avoided can be helpful. Usually, these foods addition to considering the presence of other comorbidities, are a combination of high fat and refined carbohydrates investigating which individual questions on the YFAS con- [12]. Foods to avoid can be modified throughout the tribute to a positive screen can be informative. The temporal treatment and recovery process using trial-and-error as sequence of disorder onset can also help with case conceptu- well as exposure-based therapies. alization but is only one of many puzzle pieces. It may take 4) Emphasize cooking meals at home rather than relying several sessions including some trial-and-error and discus- on purchasing prepared food. Not only does this improve sion of the pros versus cons of different approaches before the ingredients used in preparation but can foster a con- treatment trajectories become clear. nection with food (and future-directed thinking) that If a genuine UPFA exists, the steps outlined in this review reduces impulsive food choices (author anecdote). While can be used for interventions that include abstinence or harm improving the home food environment can be helpful, reduction, with the goal of improving mental health quality many individuals live with family members who con- of life rather than weight modification. While weight loss sume their trigger foods, making recovery difficult. frequently occurs in UPFA-informed interventions, provid- However, recovery can be enhanced by pursuing steps ers should emphasize weight-neutral language and weight- five through seven below. inclusive approaches to reduce weight stigma and provide 5) Target impulsivity and habitual patterns of eating by body-positive affirming care. One goal of UPFA treatment focusing on the neurobehavioral correlates of self-regu- should be to end weight-cycling and create consistency lation through practices such as mindfulness-based tech- with food. Stratifying by BMI class can aid in prioritizing niques [137, 138 ]. Interventions targeted at improving treatment goals but should not supersede other clinical con- executive function including episodic future thinking, siderations. Clinical trials are needed to improve treatment meditation, and exercise can be helpful to support recov- outcomes for UPFA and would benefit from collaboration ery of dysfunctional reward-related processes [139]. (rather than competition) from ED professionals. Cross- 6) Provide evidenced-based treatments for improving emo- disciplinary efforts from all biopsychosocial domains will tional regulation [140–142]. be critical to advance the field of food addiction. 7) Encourage resilience through social support. The per- ception of lack of social support has been associated with UPFA [143]. Targeting positive social connections Compliance with Ethical Standards is beneficial for other forms of addiction recovery and Conflict of Interest The author declares no competing interests. should not be overlooked in disorders of eating [45]. 12-Step programs such as Overeaters Anonymous is one Open Access This article is licensed under a Creative Commons Attri- well-established example [125]. The addiction frame- bution 4.0 International License, which permits use, sharing, adapta- work may reduce perceptions of personal failure [138 ] tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, which may be ameliorated through engagement with a provide a link to the Creative Commons licence, and indicate if changes like-minded community. were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not Conclusions permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a It is critical to understand the social, psychological, cog- copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . nitive, behavioral, and physiological factors in the UPFA construct [5]. This includes EDs, DR, body image distur- bance, weight stigma, and the presence of other psychiatric References comorbidities including SUDs, trauma/PTSD, depressive symptoms, and others. Providers should screen for asso- Papers of particular interest, published recently, have ciated conditions before designing clinical interventions been highlighted as: for UPFA. Clinicians should address their own conscious • Of importance or subconscious biases often when working in mental and behavioral health settings. 1.• Praxedes DRS, Silva-Júnior AE, Macena ML, Oliveira AD, Car- Individuals with UPFA require additional psychosocial doso KS, Nunes LO, Monteiro MB, Melo ISV, Gearhardt AN, support along with lifestyle modification. If not executed Bueno NB. 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Am J Lifestyle Med. 2022;16:28–31. 1 3 Current Addiction Reports 143. Li S, Schulte EM, Cui G, Li Z, Cheng Z, Xu H. Psychometric Publisher’s Note Springer Nature remains neutral with regard to properties of the Chinese version of the modified Yale Food jurisdictional claims in published maps and institutional affiliations. Addiction Scale version 2.0 (C-mYFAS 2.0): Prevalence of food addiction and relationship with resilience and social support. Eat Weight Disord - Stud Anorexia Bulimia Obes. 2022;27:273–84. 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Current Addiction Reports Springer Journals

Clinical Considerations of Ultra-processed Food Addiction Across Weight Classes: an Eating Disorder Treatment and Care Perspective

Current Addiction Reports , Volume OnlineFirst – May 2, 2022

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Abstract

Purpose of Review To examine the prevalence rates of ultra-processed food addiction across different weight classes and offer guidelines for diagnosis and treatment. Clinicians are provided with practical considerations in the assessment of ultra- processed food addiction beyond the use of validated instruments. Recent Findings The weighted mean prevalence of ultra-processed food addiction is approximately 20% worldwide and var- ies widely based on the sample. At first glance, there appears a linear relationship between ultra-processed food addiction and BMI class. Further investigation indicates a J-shaped curve with heightened prevalence among the underweight. These findings highlight the need to assess for additional factors that may increase objective or subjective food addiction symptoms including eating disorders, dietary restraint, and other mental health diagnoses. Summary While clinical considerations across different weight classes vary, overemphasis on weight status may detract from the clinical utility of the ultra-processed food addiction construct. Considering weight status in conjunction with other psychiatric symptoms helps to better understand the various biopsychosocial mechanisms that influence eating behavior and can inform individualized treatment strategies. Keywords Food addiction · BMI · Eating disorders · Dietary restraint · Weight stigma · Trauma Introduction The purpose of this review is to describe the reported prevalence rates of FA across different weight classes and to The phenomenon of food addiction (FA) has been mentioned provide clinical guidelines for diagnosis and treatment, with in over 2,500 published articles to date [1 ]. Most research particular emphasis on the underweight category. The aim studies have operationalized FA using the Yale Food Addic- is to offer clinicians practical guidelines in the assessment tion Scale (YFAS) [2] and more recently YFAS 2.0 [3] based and treatment of FA beyond the use of validated instruments. on DSM-5 criteria for substance use disorders (SUDs). FA There is growing trend toward use of the term “ultra- can be understood as hedonic eating after homeostatic require- processed food addiction” (UPFA) emphasizing noteworthy ments have been met [4, 5] with continued consumption differences from minimally processed foods in their addic- despite negative consequences [6]. Paradoxically, FA symp- tive potential [8–12]. Given that the YFAS specifically asks toms have been reported among underweight individuals who about the consumption of ultra-processed foods with added may not be meeting their energy needs [7 ], necessitating a sugars, salts, and fats, the terms FA and UPFA have been closer examination of the FA construct through the lens of used interchangeably. The UPFA nomenclature may advance eating disorder (ED) psychopathology and related symptoms. the utility and specificity of the FA construct, given that nearly 60% of the calories consumed in the USA come from ultra-processed foods [13]. Henceforth, the term UPFA will This article is part of Topical Collection on Food Addiction be used to describe the phenomenon of food addiction. While clinical considerations across different weight * David Wiss classes may vary, this review argues that overemphasis on davidawiss@nutritioninrecovery.com weight status may detract from the clinical utility of the Community Health Sciences Department, Fielding School UPFA construct. Weight (and BMI) is often analyzed as of Public Health, University of California, Los Angeles, 650 an outcome which is influenced by an array of biological, Young Drive South, Los Angeles, CA 90095, USA Vol.:(0123456789) 1 3 Current Addiction Reports psychological, social, and behavioral causes whereas addic- sequence of disorder onset. This limitation may make the tions are defined (and diagnosed) solely by behavioral cri- interpretation of rising UPFA prevalence “noisy” because teria. Thus, consideration of UPFA as a behavioral health many ED symptoms can increase YFAS scores [33 ]. Simi- disorder (rather than weight disorder) may provide more larly, UPFA can precede ED behaviors, generating a chicken insight into clinical treatment strategies. versus egg conundrum for researchers and clinicians. Several studies have failed to show significant correla- tions between UPFA and BMI [14–18]; therefore, efforts to address UPFA clinically should not be synonymous Ultra‑processed Food Addiction and Eating with weight loss. Rather, UPFA has been associated with Disorders reduced quality of life [19] through mechanisms such as emotion dysregulation [20–22] which can be targeted. Fur- Clinical samples (such as those with EDs) have higher UPFA thermore, UPFA has been associated with altered psychoso- prevalence than community-based or representative samples cial functioning more than with metabolic parameters [18]. [34]. Specifically, individuals with bulimia nervosa (BN) Meanwhile, considering one’s weight status in the clinical have the highest prevalence of UPFA (48–95%), followed evaluation of UPFA might be useful to better understand the by binge eating disorder (BED; 55–80%), and anorexia ner- • • various biopsychosocial mechanisms that influence eating vosa (AN; 44–70%) [1 , 35 , 36]. Most studies investigating behavior (including the subjective experience of it). the association between AN and UPFA found that UPFA symptoms are higher among those with AN binge-purge type (AN-BP) compared to the restrictive subtype (AN-R) [37, Ultra‑processed Food Addiction Prevalence 38, 39 , 40]. An understanding of the heterogeneity in UPFA presenta- The most recent systematic review and meta-analysis of 272 tions necessitates assessment for ED psychopathology, par- studies using the YFAS, YFAS 2.0, and derivative scales ticularly the role of restrained eating and other compensatory reported a weighted mean prevalence of UPFA diagnoses behaviors as a cause and/or consequence of UPFA symptoms • • at 20% worldwide (95% CI: 18–21%) [1 ]. The prevalence [33 ]. The symptoms of UPFA in under-to-normal weight of UPFA varies widely based on the sample under study. ranges may represent individuals exhibiting compensatory Clinical samples have higher prevalence than non-clinical behaviors (e.g., purging in BN or AN-BP, or over-exercis- samples [1 ]. A nationally representative sample from the ing) which keeps their BMI stable (or decreasing) despite USA reported UPFA prevalence at 15% [7 ], which closely the presence of addiction-like eating (e.g., bingeing, loss mirrors prevalence rates of other substance-related behaviors of control) commonly associated with weight gain [41 ]. in the USA [23]. While the prevalence of UPFA is generally It has been suggested that weight control behavior in indi- higher in women than men [24–26], these findings are not viduals with BN may dampen reported associations between consistent [7 ]. addiction-like eating and BMI [42, 43]. UPFA prevalence estimates are higher in adults com- There is a growing trend toward viewing UPFA and EDs pared to children and adolescents (15%; 95% CI: 11–19%) from a transdiagnostic perspective [44–46] particularly in [27], suggesting that symptoms develop over time, much relation to food cravings [47]. The clinical considerations like other addictions. Increased exposure to ultra-processed discussed herein are designed to improve our understand- foods may contribute to early recruitment of brain regions ing of the UPFA construct in individuals with and without associated with food consumption and choice [9]. A blunted EDs. Equally important, UPFA is frequently seen in subjects reward experience might increase overconsumption behav- without EDs (or other psychiatric disorders) in the general ior in attempt to reattain the expected reward [28]. Reward- population, which suggests that UPFA is a distinct entity related susceptibility to addictive processes may also be from EDs and other psychiatric illness [48]. exacerbated by various forms of stress, trauma, and adver- sity often associated with low socioeconomic status and unhealthful food environments [29]. Ultra‑processed Food Addiction and Body Recent studies have shown that the COVID-19 pandemic Mass Index increased the incidence rate of UPFA [30] and associated weight gain from eating behavior attributable to circum- Without a nuanced understanding of how UPFA symptoms stances such as isolation [31]. It has also been documented present clinically in the under and normal weight catego- that COVID-19 led to a surge in EDs [32]. Directionality ries, a linear relationship between UPFA and BMI might between UPFA and ED symptoms during the pandemic (and be assumed. Figure 1 is adapted from the recent Praxedes before) remains unclear. A major shortcoming in research et al. meta-analysis [1 ] and represents the broadest pos- linking UPFA to EDs is a failure to disentangle the temporal sible relationship between UPFA and BMI. The pooled 1 3 Current Addiction Reports Fig. 1 The broadest view of the relationship between BMI and ultra- Fig. 2 A closer view of the J-shaped relationship between BMI and processed food addiction prevalence from meta-analytic data reported ultra-processed food addiction prevalence from a nationally repre- • • by Praxedes et al. [1 ] sentative German sample reported by Hauck et al. [49 ] prevalence among individuals considered normal weight a homeostatic drive for food from an undernourished state was 17% (95% CI: 16–19%); among overweight was 24% [7 ]. (95% CI: 19–29%); and among those considered obese was In the next section, the literature exploring the non- 28% (95% CI: 24–32%). Not enough UPFA studies among linear relationship between UPFA and BMI categories are the underweight class were available for pooled analysis. reviewed. Furthermore, mental health considerations are At first glance, the relationship between UPFA and BMI included to assist in developing treatment strategies when appears linear. positive UPFA screens occur in different BMI categories. Other investigations of UPFA prevalence including indi- Recommendations prioritize ED recovery and are designed viduals with EDs generates J-shaped curves, with the under- to reflect weight-inclusive approaches to managing health weight category demonstrating sharply higher UPFA preva- [55 ]. An argument will be made that UPFA appears primar- • • • lence (12–46%) [7 , 41 , 49 ]. A representative USA sample ily related to eating pathology and only secondarily related indicated that the prevalence of UPFA is paradoxically high- to body weight [52]. est in the underweight category (46%) [7 ]. A representative German sample indicated UPFA prevalence among under- weight (15%) as higher than class I obesity (12%) but lower Ultra‑processed Food Addiction and Dietary than class II (21%) [49 ]. Not surprisingly, prevalence rates Restraint differ widely according to sample demographics. It is also possible that food insecurity may increase UPFA symptoms, This section reviews often overlooked clinical symptoms which may be relevant across BMI classes [50, 51]. Key among individuals with UPFA who also exhibit high levels findings from several recent studies show that obesity cannot of dietary restraint (DR). While binge eating and UPFA are be explained solely by UPFA [52–54]. not synonymous, research linking DR to binge eating will be Data from the German sample [49 ] are presented for used to conceptualize relationships between UPFA and DR. conceptual purposes in Fig. 2. The prevalence rates in Fig. 2 It is also plausible that dieters may not subjectively binge but are not intended for direct comparison to the meta-analytic rather display other characteristics of addiction-like eating findings in Fig.  1, but rather to illustrate how a more fine- such as social impairment, avoidance, and emotional dis- grained analysis of BMI reveals information that could be tress, all of which could increase UPFA severity indicators. overlooked. A non-linear relationship suggests that UPFA Published data linking UPFA and DR are mixed. Cross- is not the only contributor to weight gain and may reflect a sectional data have linked UPFA scores with higher levels distinct phenotype of problematic eating that is not synony- of DR [56] whereas the validation studies of the YFAS and mous with obesity [49 ]. It is also possible that self-reported YFAS 2.0 showed no significant correlations between UPFA UPFA symptoms in the lowest weight class are relics of diet- and DR [3, 57]. Among adolescents in a weight loss pro- ing and caloric deprivation that mimic behavioral indicators gram, UPFA was not related to eating restraint [58]. Other of addiction. Examples include eating more than intended investigations of adolescents have shown positive correla- due to a violation of dietary rules, or cravings that reflect tions between UPFA and DR [59]. Less is known about the 1 3 Current Addiction Reports temporal relationship between DR and UPFA symptoms, may experience varying effects on their body weight, par - requiring longitudinal investigations in samples with and tially depending on whether the restraint is part of a recovery without current (or prior) EDs. plan, mistargeted (i.e., excessive), inadequately supported, While it is well known that efforts to restrain eating often or part of a restrictive ED [29], which can be driven by body contribute to binge eating, other models suggest that UPFA dissatisfaction. leads to weight gain and then progress to DR [60]. This pat- tern is frequently observed among other addictive disorders. For example, repeated alcohol exposure can lead to problem- Ultra‑processed Food Addiction and Body atic use which could in turn lead a person to restrict their Image Disturbance alcohol use to mitigate these problems. The return to alco- hol (i.e., relapse) closely resembles the way some return to Body image disturbances are known correlates of DR and highly palatable foods following a period of abstinence [46]. EDs and are related to quality-of-life measures [77]. Sus- Early research among women with BN revealed that the ceptibility to attentional biases toward appearance-related first binge preceded diet onset in 9–37% of cases [61, 62]. information might be one vulnerability factor in the pro- In a cohort study of young women dieting, only 3.5% devel- longed persistence of body image disturbances in daily life oped an ED of clinical severity during the 2-year follow-up [78]. Cohort data found that the adolescent drive for thinness [63]. A recent review found no experimental support for the continues into adulthood and may predict compulsive eating DR theories of EDs, suggesting that DR may activate vul- behavior (reward-based eating) and greater BMI independ- nerability factors leading to ED symptoms but only among ent of childhood weight [79]. Body image disturbance may those already vulnerable [64]. As previously stated, DR persist over the life course and should be evaluated when may be a consequence of weight gain and the perception of treating all forms of disordered eating behavior. overeating. Therefore, divergent models are needed to bet- Body image disturbance has been independently associ- ter understand directionality between UPFA and DR [60]. ated with UPFA symptoms, suggesting that it may be one Food cravings have been linked to dieting [65], and important factor in the development and/or maintenance of efforts to restrain eating predicted future overeating during UPFA [80]. While it is likely to be a consequence of UPFA, COVID-19 through negative emotions [66]. Data on twins assessment of body image through validated instruments has shown that frequent attempts to lose weight reflect future or by clinical evaluation may be important for developing susceptibility to weight gain [67], but the precise mecha- treatment interventions. For example, if body dissatisfaction nisms remain unclear. A randomized controlled trial using drives DR which in turn contributes to UPFA symptoms, internet- and app-based intervention demonstrated that tar- targeting body image disturbances might reduce dieting and geting DR led to greater reductions in binge-eating eating improve addiction-like eating [81]. While the number of episodes compared with controls [68]. Taken together, it young people with elevated BMIs continues to grow, so has appears that DR may be one contributor to UPFA symptoms the percentage of youths experiencing body dissatisfaction such as binge eating and therefore might be a useful target and weight stigma [82], necessitating incorporation of this for clinical interventions among individuals meeting criteria discourse into public health campaigns. for UPFA, especially those with comorbid EDs. Other research suggests food reward tends to decrease during weight management interventions [69]. A study Weight Stigma using caloric restriction for at least 12 weeks reduced food cravings, supporting a deconditioning model [70]. Various Recent conceptual models have suggested that the expe- dimensions of food cravings are differentially related to out- rience of weight stigma may drive DR and contribute to comes in dieting [65]. Short-term selective food deprivation UPFA symptoms [29]. Among adolescents, UPFA signifi- increases cravings for avoided foods while long-term energy cantly mediated the association between weight-related restriction results in craving reductions, indicating a reduc- self-stigma and binge eating [83]. In a longitudinal study of tion of previously acquired conditioned responses [71]. young adults, fear of being stigmatized predicted worsening In summary, DR has been viewed as both the problem UPFA symptoms over time [84]. These studies suggest that and the solution to rising BMIs [72]. Efforts to lose weight the experience of weight stigma contributes to UPFA among or restrict food can make eating pathology worse [73–75]. some individuals. Other research suggests that understand- It is unclear whether efforts to eat differently (emphasizing ing UPFA broadly reduces weight stigma by minimizing quality rather than quantity) should be classified as disor - the blame narrative associated with “personal responsibil- dered behavior [29] including Orthorexia Nervosa [76], but ity” [85, 86]. Several authors have proposed that targeting likely depends on an individual’s psychiatric profile [33 ]. weight stigma at the societal level should be a public health Individuals who meet criteria for UPFA and engage in DR goal [87]. Targeting the internalization of weight bias can 1 3 Current Addiction Reports be beneficial among those with UPFA, regardless of their impulsive behavior when treating UPFA. A family history of weight status. SUD should be considered in the assessment [46]. Anti-obesity messaging may put vulnerable individuals In patients with both UPFA and SUD, targeted treatments at risk for EDs [88]; a highly undesirable outcome. Mean- that reduce impulsivity and increase self-directedness may while, evidence-based treatments for obesity can reduce improve treatment outcomes [97]. While this may be dif- disordered eating behaviors without increasing internal- ficult, evidence of UPFA channeled by trait levels of impul- ized weight stigma [89]. Divergent views in the field may sivity may help explain why addictive-like behaviors can arise from a failure to separate advocacy from evidence, be recalcitrant to change [21]. The associations between as well as training/discipline bias. Efforts to find a com- UPFA and impulsivity have been shown to associate with mon ground between the prevention of obesity and EDs are more frequent weight fluctuations and higher BMIs [98]. greatly needed [64]. But given that UPFA is not synonymous This information may be helpful to clinicians working with with obesity, it is imperative that researchers and clinicians disordered eating by reducing stigma surrounding eating understand the potential relationship between weight stigma pathology, advancing trauma-informed care for addictive and UPFA independent of BMI. disorders [99]. Trauma and Post‑traumatic Stress Disorder (PTSD) Ultra‑processed Food Addiction and Other Trauma, particularly early in life, has been associated Mental Health Disorders with increased BMI over the lifespan and UPFA may be one mediating mechanism [43, 100]. The risk for UPFA A detailed discussion of the associations between relevant increases following exposure to early life psychological, mental disorders and UPFA is beyond the scope of this sexual, and physical abuse [19, 101]. In fact, all forms of review. Nevertheless, some of the associations between trauma increase risk for UPFA, likely driven by PTSD symp- select mental health disorders and UPFA will be summa- toms [102]. The association between early life adversity and rized to aid clinicians treating UPFA. An 8-step assessment UPFA might be the result of multiple pathways of biological process to discern UPFA from DR using psychiatric symp- embedding [43], such as reward processing [103, 104] which toms has recently been published [33 ]. This process has not can heighten risk for SUDs [105] and impulsivity [106]. been validated but may be useful as a roadmap for conceptu- Associations between early life trauma and EDs are well- alizing UPFA treatment in the context of EDs (emphasizing described [107, 108] but efforts to investigate the role of DR as a proxy for restrictive behaviors associated with EDs). UPFA as a mediator, moderator, or outcome are limited. UPFA, as well as emotional eating, have been shown to Substance Use Disorders mediate the relationship between psychological distress and BMI [109]. Based on the available evidence, it appears Research linking UPFA to SUDs are mixed. There is some important to look for signs of trauma and PTSD when evidence of elevated UPFA prevalence in those with SUDs designing interventions for UPFA. Considerations include [90] as well as cross-addiction between food and substances the mechanisms of biological embedding that may impact of abuse [91] but these associations were not statistically eating behavior as well as the possibility that some nutrition significant in a recent meta-analysis [92]. Nevertheless, interventions (e.g., excessive DR) can be triggering for some UPFA has been associated with a family history of addic- individuals, particularly those with food-related trauma (e.g., tion [20] and brain reward dysfunction [11]. Based on clini- parents who imposed dieting and body shaming [110]). cal experience, many individuals with severe UPFA do not cross-addict into other substances, partly because highly Depressive Symptoms palatable foods are always available and therefore remain the substance of choice (or no choice). In a systematic review and meta-analysis, the weighted Impulsivity strongly correlates with problematic sub- mean correlation between UPFA and depression was 0.46 stance use [93, 94] and is consistently associated with UPFA (95% CI: 0.36–0.55) [92]. This relationship is bidirectional [95]. While it has been suggested that a history of SUD and may be important for psychoeducation in those with might help with clinical implications of UPFA [33 , 46], UPFA. Ultra-processed food consumption increases the risk impulsivity might be a more informative concept. Higher of developing depression [111, 112] while “Mediterranean- distress-driven impulsivity has been associated with more Style” eating patterns have been associated with reductions addiction-like eating behaviors among participants clas- in these symptoms [113]. Thus, when depressive symptoms sified as cognitively inflexible [96]. Thus, the presence of are present, patients with UPFA should be counseled to eat any current or previous SUD may be a proxy measure for in ways known to reduce these symptoms [114]. 1 3 Current Addiction Reports There is a U-shaped curve between BMI and depression, 2) Assess for the presence of AN, particularly AN-BP. If where the highest rates occur in underweight and obese cate- present, the current evidence-based treatment includes gories [115]. It is plausible that associations between under- weight restoration [120]. Obsessive–compulsive disor- weight and depression stem from undernutrition, although ders and anxiety frequently occur when AN is present this is not well documented. From clinical experience, coun- [121, 122]. In patients with AN-R, a high YFAS score seling efforts focused on mental health outcomes such as often reflects fear of overeating, bingeing, or loss of con- depressive symptoms rather than weight are welcomed by trol rather than the actual behavior [123]. This concept is most patients (once recent data on weight science have been supported by evidence of AN patients reporting greater discussed). UPFA symptomatology while being able to success- fully regulate their food cravings [124]. Recent research has suggested there are two distinct phenotypes among Clinical Considerations of Ultra‑processed those with co-occurring AN and UPFA: (1) restriction Food Addiction Across Weight Classes that drives perceived or actual UPFA symptoms; and (2) genuine UPFA that is premorbid to AN, where a In this final section, clinical considerations for UPFA are heightened reward response to ultra-processed foods broken down by weight classes, with emphasis on the under leads to restriction or fasting [39 ]. If the latter is pre- and normal weight categories. Differentiation by weight sent, nutrition interventions aimed at reduced exposure status does not imply that UPFA treatment should be deter- to ultra-processed foods while simultaneously pursuing mined by BMI alone, but rather that BMI might influence weight restoration may be clinically appropriate. It may intervention priorities. It is important to distinguish UPFA also be useful to discuss the pros and cons of engaging from restrictive EDs before UPFA-related treatment is in a 12-Step program for compulsive eating, as these implemented. groups can be attractive to those feeling misunderstood Recommendations are generated from available evidence by clinicians but can reinforce restrictive ED symptoms and the clinical experience of the author which have not in some cases [125]. been validated. Systematic reviews of interventions for 3) It is important to assess for DR and other compensatory UPFA have recently been published [116, 117]. Ketogenic behaviors (e.g., excessive exercise) in the absence of diets used in the treatment of binge eating and UPFA [118, clinically significant ED that may be driving weight loss. 119] are controversial and are not discussed here but may If these behaviors are driven by body dissatisfaction, have utility in select cases. therapeutic interventions aimed at promoting positive body image can be helpful [126]. When present, it is Underweight important to address restrained eating and the relentless pursuit of thinness as risk factors for EDs and potential The heightened prevalence of UPFA among those in the predictors of compulsive eating and rebound weight gain underweight BMI category and its treatment has not been later in life [79]. Investigating weight history is informa- well described. When other comorbid conditions have been tive to better understand metabolic and psychological identified, it is useful to explore the items on the YFAS concerns associated with weight-cycling [127]. After that specifically contribute to elevated UPFA scores. An weight restoration, the goal is weight stability. Outcomes interview-style assessment is helpful to ascertain if these are improved when a registered dietitian nutritionist spe- individuals engage in objective or subjective overeating [7 ]. cialist is involved [128]. Other questions such as changing social, occupational, or 4) It is important to assess for the presence of current SUD recreational activities, or continuing to eat despite physical which may drive malnutrition [129]. When present, or psychological problems may reflect subjective experi- evidence-informed recommendations should address ences, especially when considering ultra-processed foods the specific substances used [130] while abstinence or that often elicit moral judgments about these foods [34]. harm-reduction strategies are being pursued. The six clinical considerations below are derived from an 5) Determine if trauma symptoms or trauma history is expanded 8-step process designed to help separate overlap- present and provide general psychoeducation that links ping signs and symptoms of UPFA and DR [33 ] but did not adversity to food and body issues as one part of an estab- consider differences across BMI categories. When UPFA is lished evidence-based trauma treatment [131]. Over- detected among the underweight class: looking trauma may contribute to poor treatment out- comes because unresolved adversity may be considered 1) Rule out food insecurity or other forms of socioeco- a fundamental cause of all downstream psychopathology nomic disadvantage or deprivation that might be elevat- [132]. ing UPFA symptoms. 1 3 Current Addiction Reports 6) Evaluate for depressive symptoms and if present, con- tribute to this outcome, aiming to reduce addiction-like sider the possibility that undernutrition, body image eating gradually over time. disturbance, or pathological restrained eating is con- tributing to this outcome and target all three potential Overweight/Obesity vulnerability factors. In some cases, anti-depressant medications may be indicated. All weight categories above normal have been merged to emphasize that UPFA recovery can be pursued independent of weight status. Clinicians and patients may assume that Normal Weight weight loss is the key outcome of UPFA recovery, but this assumption detracts from important quality of life outcomes The normal weight class has the lowest UPFA prevalence, which should be prioritized. The likelihood of transitioning but there are important clinical considerations which aim to from an obese classification to normal weight over a 9-year distinguish contributions from EDs such as BN and BED. period is less than 1% [133]. For this reason, other goals Much like the underweight category, investigating the spe- such as reducing disordered eating, other addictive behav- cific YFAS questions which lead to a positive UPFA screen iors, trauma symptoms, and depressive symptoms should be might help clarify subjective versus objective overeating. prioritized. When patients lose weight during UPFA treat- Once this assessment has been made, continue to the steps ment, it is often the result of better nutrition and lifestyle outlined for the overweight/obese class. Treatment for UPFA habits, as well as improved stress management. One way to in the normal weight class includes: deemphasize weight in UPFA treatment is to avoid weigh- ing people throughout treatment, as well as discourage them 1) Investigate BN and BED and address associated behav- from weighing themselves. iors such as bingeing, purging, and restricting with the If UPFA is detected among the overweight/obese class, goal of reducing or eliminating these behaviors. Absti- the steps outlined for normal weight should be pursued first. nence from purging is an important goal but may take Once these considerations have been made, UPFA may exist time, particularly in outpatient settings. Identifying as a separate entity from an ED or other diagnosis. When “trigger foods” with the goal of abstinence is controver- UPFA has become the primary target for recovery: sial among ED professionals. It can be helpful to deter- mine the order of UPFA or ED manifestation. If the ED 1) Create a meal strategy that is consistent in nutrients with came first, traditional ED treatment which incorporates positive sensory experiences with food. Avoiding hunger these foods might be the safest course. One of the goals and gaps in nutrients are important in creating a consist- of normalizing these foods is to disrupt the cognitive ent (yet varied) experience with food to reduce hedonic distortion of good versus bad foods. If UPFA appeared overeating [134 ]. For example, three meals plus one or first, consider excluding specific foods that contribute two snacks containing all the macronutrients at meals. to bingeing, but only after other clinical considerations Deficiencies in fiber, protein, and fat might contribute to have been identified. hunger which could increase the risk for hedonic eating. 2) Same as #3 for the underweight class. Discussion of Meals and snacks consumed throughout the day should weight stigma in society and internalized weight bias include food that is hot, cold, crunchy, creamy, savory, can be helpful. A common goal is to avoid the relent- and sweet (i.e., fruit). Over-restricting caloric intake is less pursuit of thinness by stressing consumption of an not recommended, as the goal is to reduce symptoms of appropriate amount of food from all macronutrient cat- UPFA [134 ]. Cravings should diminish over time and egories at meals and throughout the day. emphasizing patience is critical. 3) The clinician should assess for comorbidities such as 2) Switching the goal from weight loss to improved mental SUDs which may be contributing to addiction-like eat- health quality of life can reduce the perception of weight ing. If present, use substance-specific protocols [ 130] stigma. Addressing internalized weight bias might while pursuing abstinence or harm-reduction strategies. reduce feelings of stress and adversity that in turn make The temporal sequence between disorders of food and improvements in eating more accessible [29]. Treatment other substances should be investigated. If UPFA symp- professionals should discuss the issue of fat shaming in toms clearly preceded other substance use, this may society [135]. favor moving toward abstinence from addictive foods, 3) Move toward a low glycemic carbohydrate diet (e.g., after other clinical considerations have been made. beans and high-fiber whole grains) given that high gly - 4) Same as #5 for the underweight class. cemic carbohydrates (e.g., refined grains and added 5) Same as #6 for the underweight class with additional sugars) can interact with mesolimbic dopamine systems consideration that excessive reward activation may con- that heighten food cravings and may lead to loss of con- 1 3 Current Addiction Reports trol [45, 136]. Identifying individual trigger foods that for clinically significant EDs among vulnerable groups. In should be avoided can be helpful. Usually, these foods addition to considering the presence of other comorbidities, are a combination of high fat and refined carbohydrates investigating which individual questions on the YFAS con- [12]. Foods to avoid can be modified throughout the tribute to a positive screen can be informative. The temporal treatment and recovery process using trial-and-error as sequence of disorder onset can also help with case conceptu- well as exposure-based therapies. alization but is only one of many puzzle pieces. It may take 4) Emphasize cooking meals at home rather than relying several sessions including some trial-and-error and discus- on purchasing prepared food. Not only does this improve sion of the pros versus cons of different approaches before the ingredients used in preparation but can foster a con- treatment trajectories become clear. nection with food (and future-directed thinking) that If a genuine UPFA exists, the steps outlined in this review reduces impulsive food choices (author anecdote). While can be used for interventions that include abstinence or harm improving the home food environment can be helpful, reduction, with the goal of improving mental health quality many individuals live with family members who con- of life rather than weight modification. While weight loss sume their trigger foods, making recovery difficult. frequently occurs in UPFA-informed interventions, provid- However, recovery can be enhanced by pursuing steps ers should emphasize weight-neutral language and weight- five through seven below. inclusive approaches to reduce weight stigma and provide 5) Target impulsivity and habitual patterns of eating by body-positive affirming care. One goal of UPFA treatment focusing on the neurobehavioral correlates of self-regu- should be to end weight-cycling and create consistency lation through practices such as mindfulness-based tech- with food. Stratifying by BMI class can aid in prioritizing niques [137, 138 ]. Interventions targeted at improving treatment goals but should not supersede other clinical con- executive function including episodic future thinking, siderations. Clinical trials are needed to improve treatment meditation, and exercise can be helpful to support recov- outcomes for UPFA and would benefit from collaboration ery of dysfunctional reward-related processes [139]. (rather than competition) from ED professionals. Cross- 6) Provide evidenced-based treatments for improving emo- disciplinary efforts from all biopsychosocial domains will tional regulation [140–142]. be critical to advance the field of food addiction. 7) Encourage resilience through social support. The per- ception of lack of social support has been associated with UPFA [143]. Targeting positive social connections Compliance with Ethical Standards is beneficial for other forms of addiction recovery and Conflict of Interest The author declares no competing interests. should not be overlooked in disorders of eating [45]. 12-Step programs such as Overeaters Anonymous is one Open Access This article is licensed under a Creative Commons Attri- well-established example [125]. The addiction frame- bution 4.0 International License, which permits use, sharing, adapta- work may reduce perceptions of personal failure [138 ] tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, which may be ameliorated through engagement with a provide a link to the Creative Commons licence, and indicate if changes like-minded community. were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not Conclusions permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a It is critical to understand the social, psychological, cog- copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . nitive, behavioral, and physiological factors in the UPFA construct [5]. This includes EDs, DR, body image distur- bance, weight stigma, and the presence of other psychiatric References comorbidities including SUDs, trauma/PTSD, depressive symptoms, and others. Providers should screen for asso- Papers of particular interest, published recently, have ciated conditions before designing clinical interventions been highlighted as: for UPFA. Clinicians should address their own conscious • Of importance or subconscious biases often when working in mental and behavioral health settings. 1.• Praxedes DRS, Silva-Júnior AE, Macena ML, Oliveira AD, Car- Individuals with UPFA require additional psychosocial doso KS, Nunes LO, Monteiro MB, Melo ISV, Gearhardt AN, support along with lifestyle modification. If not executed Bueno NB. 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Journal

Current Addiction ReportsSpringer Journals

Published: May 2, 2022

Keywords: Food addiction; BMI; Eating disorders; Dietary restraint; Weight stigma; Trauma

References