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Purpose of Review The majority of existing research discusses food addiction (FA) classification, which provides information for different groups and which groups may or may not be affected to differing degrees. Fewer studies report FA symptom scores, and fewer still report on individual symptoms. This paper discusses the symptoms of craving and loss of control as they are common FA symptoms that demonstrate similarities with both substance use disorders and some eating disorder pathology. Recent Findings Loss of control presents parallels with disordered eating, particularly binge eating disorder. Craving refers to the powerful or strong desire for something and, in contrast to lack of control, presents most overlap with substance use disorders. Summary While not the most common symptoms reported in published research, loss of control and craving attract atten- tion because of parallels with substance use and eating disorder pathology, and research has increasingly focused on these symptoms in recent years. Keywords Food addiction · Eating addiction · Ultra-processed food addiction · Loss of control · Craving Introduction versions the Yale Food Addiction Scale (YFAS) [3, 6]. The YFAS can be scored and reported in several ways, includ- The current state of the literature highlights that food addic- ing a FA classification/diagnosis, level of FA severity (mild, tion is not a homogenous condition but a multi-faceted and moderate, severe), total symptom score and endorsement at transdiagnostic condition arising from a complex number the individual symptom level [3, 6]. The majority of existing • • of individual factors [1 , 2 ]. A range of terms have been research discusses FA classification, which provides infor - used in the literature to date to describe the food addiction mation for different groups and which groups may or may construct  including eating addiction, which is more not be affected to differing degrees. Fewer studies report reflective of the behavioural aspects [ 4], and more recently on symptom scores, and fewer still report endorsement of •• ultra-processed food addiction [5 ]. The differences in individual symptoms. The aim of this narrative review is to nomenclature highlight the diversity of current research, discuss the symptoms of craving and loss of control (LOC), with the food addiction construct being of interest to a range with a focus on research in recent (i.e. the last 5) years. of researchers and clinicians from various backgrounds. This Craving and LOC are common symptoms that demonstrate paper will use the term food addiction (FA), which most similarities between FA and both substance use disorders research operationalises and reports using one of the various and some eating disorder pathology and, for these reasons, demonstrate considerable interest. This article is part of the Topical Collection on Food Addiction Food Addiction Classification * Tracy L. Burrows email@example.com FA research is largely dominated by studies in adults, par- Nutrition and Dietetics, School of Health Sciences, College ticularly females, and in these studies, FA often presents Health Medicine and Wellbeing, University of Newcastle, •• •• • in its severe form [7 , 8 , 9, 10 ]. These studies indicate ICT Building 375, University Dr, Callaghan, NSW 2308, that on the YFAS 2.0, individuals endorse six or more Australia of the 11 symptoms (Table 1), in addition to the clinical Food and Nutrition Program, Hunter Medical Research impairment or distress criterion, meaning that it negatively Institute, University of Newcastle, New Lambton Heights, NSW 2305, Australia 1 3 Current Addiction Reports (2022) 9:318–325 319 impacts their day-to-day functioning. Clinical impairment more broadly, as well as global variations in eating culture or distress from FA has been specifically investigated as and presentation of similar constructs (e.g. binge eating), this criterion influences whether an individual is classified are important considerations in future research in this area. as FA or not. Clinical impairment or distress is more often reported among women than men and among people with obesity than those who are categorised as overweight [11, Food Addiction Symptomology 12]. This is an interesting factor in research exploring FA prevalence and highlights why other methods of scoring, While many papers discuss FA classification or diagnosis, such as symptom scores with and without the endorse- providing information in different population groups and ment of clinical distress or impairment criterion, should be subgroups which may or may not be affected to differing considered further. For example, an individual endorsing degrees, systematic reviews show that fewer studies report 11 symptoms, but not clinical impairment or distress, may on individual symptoms . For example, in a systematic benefit from further assessment measures and be high - review of 51 studies exploring FA and associations with lighted as ‘at risk’. Wiss and Brewerton provide sugges- mental health, only 20 studies reported symptom scores . tions for the assessment of FA and differential diagnosis Similarly, in a recent review of studies that use versions of . Specifically, they describe a comprehensive approach the YFAS 2.0 tool, 53 studies were included with fewer stud- for assessing FA that takes into consideration factors such ies reporting symptom scores compared with classification/ as dietary restraint and comorbid psychiatric disorders. diagnosis . Through distinguishing FA from other forms of eating Previous reviews report that the average symptom score pathology, this approach may help to guide case formula- differs for population subgroups, with clinical samples often tion and treatment planning which is likely not a one size endorsing more symptoms than non-clinical samples [9, 12, fits all approach for FA management. 17]. A 2014 systematic review of FA prevalence found that While most FA research has been conducted in adults, 16 of 25 included studies reported on FA symptoms, with a recently, there has been a growing amount of literature mean of 4.0 FA symptoms endorsed in clinical studies and in younger age groups. This includes children and ado- 1.7 FA symptoms in non-clinical studies . More recently, lescents [15 ] and with more equal sex representation in a 2018 review and meta-analysis of FA associations with these studies. Evidence from a recent systematic review mental health (n = 51 studies) found that the mean number including 27 studies carried out in adolescents suggests of FA symptoms in those seeking treatment for weight loss that FA in this younger population is most often reported (n = 9 studies) was 3.0 (upper and lower limit 2.7–3.4) and in its mild/moderate form, indicating fewer symptoms are 5.2 (3.6–6.7) for those with disordered eating (n = 7 stud- endorsed [15 ]. This is in contrast to the adult literature ies) . and may indicate a progression in severity as someone Of those studies that report symptoms, the reporting is transitions from adolescence to adulthood. In addition, quite diverse with some reporting mean number of symp- publications have emerged which have considered impor- toms only, while others report on the endorsement of indi- tant insights that demonstrate how FA symptoms occur vidual symptoms. This is an important level of detail or cross-culturally and that there may be significant differ - distinction to consider given that some symptoms may not ences between sociodemographic groups . Specifi - be entirely specific to FA but relate to eating in general, for cally, highlighting issues related to adequate lexicalisation example, ‘persistent desire or repeated unsuccessful attempts of concepts central to FA, including craving and addiction to cut down foods’. Many people in the general population Table 1 Yale Food Addiction Scale (YFAS 2.0) criteria for food addiction (2016) * 1. Substance (certain foods) taken in larger amount and for longer period than intended 2. Persistent desire yet repeated unsuccessful attempts to quit 3. Great deal of time spent to obtain, use, and/or recover certain foods 4. Important social, occupational, or recreational activities given up or reduced due to addictive-like eating behaviour 5. Consumption of certain foods despite knowledge of adverse physical/emotional consequences 6. Tolerance (marked increase in amount of certain foods consumed; marked decrease in desired affective experience) 7. Withdrawal symptoms when cutting down or abstaining from certain foods and consumption of certain foods to relieve withdrawal 8. Craving for certain foods 9. Failure to fulfil role obligations due to addictive-like eating behaviour 10. Consumption of certain foods despite interpersonal/social consequences 11. Consumption of certain foods in physically hazardous situations *Table adapted from Schulte et al.  1 3 320 Current Addiction Reports (2022) 9:318–325 who have experienced or trialled some form of dieting are by showing a reduction in the level of endorsement. These likely to endorse this symptom . The symptoms of loss included ‘continued use despite problems’, ‘inability to cut of control and craving often receive the most attention due down’, ‘large amount of time spent’, ‘given up activities’, to their perceived overlap with existing eating disorders. In ‘tolerance’ and ‘withdrawal’. Similarly, a pilot randomised the above-mentioned review of 51 studies exploring FA and controlled trial of a brief intervention for addictive overeat- associations with mental health , among the twenty stud- ing in adults found no significant between group differences ies which reported on symptoms, the most common were in YFAS 2.0 total symptom scores pre- and post-intervention ‘repeated unsuccessful attempts to cut down’ (n = 13 studies) compared with waitlist control [23 ]. However, there were and ‘consumption despite significant consequences’ ( n = 6 significant reductions over time in the following individual studies). In another review, the most commonly reported symptoms: ‘substance taken in larger amounts’, ‘persistent symptom across studies was ‘the persistent desire or unsuc- desire’, ‘time to obtain’, ‘tolerance’, ‘withdrawal’ and ‘fail- cessful attempts to cut down foods’ . Similarly, in a ure to fulfil role obligations’. sample of patients applying for bariatric surgery, ‘persistent desire or unsuccessful efforts to cut down or control con - sumption of certain foods’ was the most prevalent symptom Loss of Control and Craving reported by 93.1% of study participants . In a recent review of FA in adolescents (n = 27 studies) While craving and LOC are not the most common symptoms [15 ], 16 studies reported symptom scores, and 15 studies of FA in reported literature, they are frequently reported reported the frequency of symptom endorsement. Mean by individuals with FA. This includes qualitative studies in •• symptom scores ranged from 1·0 to 5·2. Similar to studies in those with lived experience [24 , 25] and in studies where adults, scores were found to be higher in clinical compared FA is assessed and operationalised using tools such as the to non-clinical samples. YFAS , the Three-Factor Eating Questionnaire , the From 13 studies using the YFAS or YFAS for children Power of Food Scale  and the Loss of Control over Eat- (YFAS-C), the most common symptom endorsed was a ing Scale , among others . Craving and LOC are ‘persistent desire or repeated unsuccessful attempts to quit’ also symptoms common to substance use disorders and sub- with a mean endorsement across studies of 62·7%. Of the types of disordered eating, namely, binge eating disorder two studies using the YFAS 2·0, one study in a non-clinical (BED) and bulimia nervosa (BN). However, craving is not sample reported ‘substance often taken in larger amounts or thought to be a causal mechanism of eating disorders but over a longer period than was intended’ (13·7% study par- is considered more broadly to be an indirect contributor to ticipants) to be the most common symptom, while the other overeating behaviours. For instance, dietary restraint, which in a clinical sample reported ‘withdrawal’ (44·0% study par- is thought to elevate craving, has been identified as a causal ticipants) as the most common [15 ]. trigger of binge eating episodes . While in substance use The symptom level of detail is important, given the area disorders, craving is directly thought to trigger relapse and of research is evolving and more recently there is the emer- as such interventions focus on craving management . gence and trialling of new treatments for the management Most research of FA is reported via use of the aforemen- •• [8 , 20] of addictive eating. It has been suggested that FA tioned self-report tools that align with other substance use symptoms tend to be stable over time in adults and that the disorders [3, 14]. It is however important to consider the recurrent set of behaviours do not change unless acted on or behavioural aspects of addictive eating and to consider that intervened . However, from the perspective of symptom looking at FA solely from the perspective of substance use management or determining if individual symptoms can be may limit diagnosis and overlook underpinning behavioural changed over time, some specific symptoms may be more components of FA . amenable to change than others, for example, the level of When considering LOC and craving, it is important to con- craving or level of withdrawal experienced rather than other sider the range of contexts in which these can be applied to symptoms such as the persistent desire to quit. A recent sys- FA. For some, addictive eating could be about the specific tematic review of FA treatment studies identified nine inter - foods consumed, which are typically reported as being ultra- •• vention studies [8 ]; however, only one reported at the indi- processed foods. That is craving for a specific food and LOC vidual symptom level . This study, a weight loss focused when consuming a particular food. Ultra-processed foods are a intervention in children, used the YFAS-C to measure the combination of mostly industrial use ingredients, such as high- endorsement of individual FA symptoms within each of the fructose corn syrup, hydrogenated oils, hydrolysed proteins seven diagnostic criteria pre- and post-intervention . and flavour enhancers, which are formulated into food prod - Although this study reported no significant differences in ucts by a series of industrial processes . Ultra-processed symptoms pre- and post-intervention in a sample of 26 ado- foods include, for example, sugar-sweetened drinks, choco- lescents with obesity, six of the seven symptoms did improve late, savoury biscuits and reconstituted meat products. The best 1 3 Current Addiction Reports (2022) 9:318–325 321 definition and classification system for ultra-processed foods Interestingly, a comparison of demographic characteristics is the NOVA system, devised by Monteiro et al. in 2009 , and health-related quality of life between individuals with which categorises foods into four groups based on the level of objective versus subjective binge eating found no signic fi ant processing (unprocessed or minimally processed foods, pro- differences, providing support for a change in eating disor - cessed culinary ingredients, processed foods, ultra-processed ders diagnostic criteria to be inclusive of subjective as well foods). A recent systematic review exploring dietary intakes as objective binge eating . associated with addictive eating behaviours identified 15 stud - There have been previous reports that FA may be a •• ies, predominantly conducted in adults (n = 12) [7 ]. From sub-type of disordered eating and that the FA construct this review, the foods commonly associated with addictive is an indicator of higher eating disorder severity . eating were those high in fat and refined carbohydrates, while Studies comparing individuals with LOC eating who do individuals that met the criteria for FA were found to have sig- and do not have objectively large binge episodes have nificantly higher intakes of energy, carbohydrates and fats than found that the degree of LOC is more important than those without FA. When considering the broad research area binge size to psychological and behavioural outcomes •• of FA, 15 studies are few studies to explore this association, [40 ]. Greater LOC had a stronger independent asso- and of these, only one study was identified that investigated ciation than binge size with higher total eating psycho- processed foods as defined by the NOVA classification system. pathology, shape dissatisfaction, hunger, food cravings •• For other individuals, FA could be about volume eating and FA symptoms [40 ]. This is interesting as recent to gain a greater intensity of fullness or satiety as a sense of research has shown that in some individuals with FA, it reward rather than the specific food. In these cases, craving may be separate from binge eating as there may not be and LOC may be applied to food more generally. The vol- a distinct period of bingeing or overeating but instead ume of food consumed and sense of reward achieved from grazing  in which the quantity of food consumed may this may be an alternative driver of addictive eating behav- remain consistent from day to day. There is emergence of iour for some individuals. This may be in the form of recur- several grazing tools that may be considered alongside the ring binge eating episodes, with evidence demonstrating that assessment of FA, food intake and binge eating in future there is some overlap between FA and BED . However, research, including the Short Inventory of Grazing (SIG) the overconsumption of food may occur in the form of graz- and the Grazing Questionnaire (GQ) [36, 41]. Research ing episodes across the day or night , with more recent suggests that FA does show overlap with several disor- measurement tools being developed that assess grazing in dered eating phenotypes, with the majority of existing terms of frequency and associated emotions, including LOC research investigating BED and BN rather than other dis- . Further, grazing that is associated with FA has been ordered eating categories such as anorexia nervosa (AN) shown to contribute unique variance to the YFAS symptom [42, 43]. However, more recently, there has been emer- score . These findings provide interesting insight into the gence of FA research and overlap with AN, and while it association between a grazing pattern of overeating and FA may be a surprising finding, there have been reports that and emphasise that similar to traditional addiction disorders this is thought to ref lect the element of control . such as alcoholism, binge consumption is not the only pat- In studies that have assessed binge eating and FA, over- tern of compulsive intake . lap has been shown but not in its entirety [34, 45]. In one study, binge eating was assessed through the Binge Eat- ing Scale (BES) and addictive eating behaviours through Loss of Control the YFAS (n = 1344) . The prevalence and severity of both FA and binge eating increased across weight cat- The symptom of LOC in FA is operationalised through the egories. The overall correlation between the total score YFAS symptom ‘substance (certain foods) taken in larger from the BES and FA symptoms was r = 0.76, p < 0.001; amount and for longer period than intended’. It is a subjec- for females, it was r = 0.77, p < 0.001; and for males, it tive term and the element that is most often discussed when was r = 0.65, p < 0.001. Total BES score and the BES emo- considering FA in parallel with disordered eating. When we tion factor were most often associated with FA symptoms, consider LOC within the broader field of disordered eating, as was demonstrated to produce stronger correlations with there are some attempts to separate objective from subjective FA symptoms. In contrast, the BES behaviour factor was binge eating [37, 38]. For example, objective binge eating is less strongly associated to FA with the majority of corre- defined as LOC during eating combined with consumption lations < 0.6. In another study, it was identified that there of an unusually large amount of food, determined by trained was overlap between FA and BED symptoms, with 92% of clinical interviewers . In contrast, subjective binge eat- the individuals with BED meeting criteria for mild, moder- ing can be LOC without the unusually large amounts of food ate or severe FA assessed by the YFAS 2.0 . However, consumed yet considered as excessive by the individual. the point was also made that research needs to look beyond 1 3 322 Current Addiction Reports (2022) 9:318–325 symptoms and explore underlying mechanisms that overlap obesogenic diets using animal models found overlapping and differ between FA and BED. neuroadaptations . In humans, neuroimaging studies The broader element of control should also be consid- have demonstrated that both food and drugs of abuse can ered in the context of FA. Qualitative research provides the stimulate dopamine-based reward pathways , provid- •• • opportunity to explore this in greater depth [24 , 47, 48 ]. ing support that FA may operate similarly to substance use Qualitative studies with individuals with lived experience of disorders. Further, a systematic review and meta-analysis FA have identified several elements, with the most common of excitatory neuromodulation interventions (n = 22) aim- being that the experience of FA was about difficulty and ing to reduce craving and consumption in individuals with •• • inability in gaining control [24 , 48 ]. One study found drug addiction (n = 18) or overeating behaviour (n = 4) found that individuals felt LOC was a cause of their addictive-like immediate and longer term reductions in craving and con- eating , while in another more recent study, the theme of sumption in drug addiction and overeating interventions control was found to have three sub-themes including con- . Links between substance use and FA in relation to trolling actions around food, weight and relative to self-set craving have also drawn on research into cue reactivity . •• timeframes for making change [24 ]. Pre-occupation with Research in substance use has demonstrated that exposure food and eating has also been commonly reported by indi- to cues related to substance use, for example, the sight of •• • viduals with FA, including unrelenting cravings [24 , 48 ]. drugs, induces craving among other physiological responses . The combination of cue exposure and induced craving has been found to then increase the likelihood of substance Craving use . This has also been explored in relation to food, with a review and meta-analysis of such studies (n = 45) Craving refers to the powerful or strong desire for some- finding that both food cue reactivity and cue-induced crav - thing. Craving was added as a symptom to the YFAS in ing had a medium effect size on eating and weight outcomes 2016 when revisions were made to the original YFAS tool in the short and long term . (2009) to align with the Diagnostic and Statistical Manual A recent review on FA combined perspectives from of Mental Disorders (DSM-V) criteria (i.e. YFAS 2.0) [6, experts in addiction, nutrition, psychology and neurosci- •• 49]. Craving is self-reported and therefore subjective. Many ence backgrounds [57 ]. Interestingly, the role of craving people report cravings towards particular foods, commonly was discussed in two ways. Firstly, certain foods or food cited are chocolate, chips and sweets or lollies [23 , 50]. components may be craved as discussed above, most likely However, this does vary from one person to the next, and for ultra-processed foods or shared components of these foods this reason, tools such as the YFAS typically use terminol- such as sugar and/or fat. Secondly, the metabolic response ogy such as ‘certain foods’ which individuals can interpret to consuming such foods, for example, changes in blood glu- as whichever foods are relevant to their experience of addic- cose and hormone levels, may be linked to their craving and tive eating. addictive potential. In contrast to LOC, this symptom when discussed in the context of FA presents the most overlap with substance use disorders. In addition to this, other symptoms such as toler- Conclusion ance and withdrawal also present similarity. In substance use disorders, the craved substance is the individuals’ sub- This paper discusses two of the symptoms associated with stance of choice, typically a more potent form of the plant, addictive eating and considers them in the context of both substance or other from which it was derived, e.g. cocaine eating disorders and substance use disorders. Findings from the coca plant. Higher intakes of ultra-processed foods from this review demonstrate the many parallels that exist have been observed in association with FA . This may between LOC and eating disorders, particularly BED, and suggest that these foods and/or individual components of craving and substance use disorder. Additionally, both them are facilitative of an addictive response and therefore symptoms are often presented in the context of highly pal- craving of them, similar to the process of substance addic- atable or ultra-processed foods. Currently, there are a lim- tion. Ultra-processed foods are manufactured to be highly ited number of intervention studies in FA. While the review palatable by combining multiple processed ingredients to does not consider the broader range of FA symptoms or the achieve optimised sensory properties, which may induce clinical impairment or distress criterion, it provides further craving. For these reasons, there have been suggestions that understanding of how LOC and craving may be targeted in evolving interventions should consider both personalised as future research. Specifically, it will be important to evalu - well as societal level changes . ate how eating disorder and substance use disorder manage- Investigation into the neurobiological mechanisms ment strategies and approaches may be incorporated into involved in compulsive behaviour driven by drugs and FA intervention plans. Further, clinical trials examining 1 3 Current Addiction Reports (2022) 9:318–325 323 care perspective. Curr Addict Rep. 2022:1–13. https://doi. or g/ intervention efficacy on individual symptoms will be par - 10.1007/ s40429- 022- 00411-0 . Review of ultra-processed FA ticularly relevant. and the associations with weight status and mental health conditions. Provides important clinical considerations for Acknowledgement Tracy Burrows is supported by a National Health the assessment of FA. and Medical Council (NHMRC) Emerging Leader Fellowship. 6. Gearhardt AN, Corbin WR, Brownell KD. Development of the Yale Food Addiction Scale version 2.0. Psychol Addict Behav. Funding Open Access funding enabled and organized by CAUL and 2016;30(1):113–21. https:// doi. org/ 10. 1037/ adb00 00136. its Member Institutions 7.•• Pursey KM, Skinner J, Leary M, Burrows T. The relationship between addictive eating and dietary intake: a systematic review. Nutrients. 2022;14(1). https:// doi. or g/ 10. 3390/ nu140 10164. Declarations Systematic review that consolidates evidence of the nutri- ents, foods and dietary patterns that may be associated with Conflict of Interest The authors declare no competing interests. addictive eating. 8.•• Leary M, Pursey KM, Verdejo-Garcia A, Burrows TL. Current Human and Animal Rights and Informed Consent This article does not intervention treatments for food addiction: a systematic review. contain any studies with human or animal subjects performed by any Behav Sci. 2021;11(6). https:// doi. org/ 10. 3390/ bs110 60080. A of the authors. systematic review of intervention studies that have been tri- alled for the treatment and management of addictive eating. This will assist in informing future strategies to reduce FA Open Access This article is licensed under a Creative Commons Attri- outcomes in adults. bution 4.0 International License, which permits use, sharing, adapta- 9. Burrows T, Kay-Lambkin F, Pursey K, Skinner J, Dayas C. tion, distribution and reproduction in any medium or format, as long Food addiction and associations with mental health symp- as you give appropriate credit to the original author(s) and the source, toms: a systematic review with meta-analysis. J Hum Nutr Diet. provide a link to the Creative Commons licence, and indicate if changes 2018;31(4):544–72. https:// doi. org/ 10. 1111/ jhn. 12532. were made. The images or other third party material in this article are 10.• Praxedes DRS, Silva-Júnior AE, Macena ML, Oliveira AD, Car- included in the article's Creative Commons licence, unless indicated doso KS, Nunes LO, et al. Prevalence of food addiction deter- otherwise in a credit line to the material. If material is not included in mined by the Yale Food Addiction Scale and associated factors: the article's Creative Commons licence and your intended use is not a systematic review with meta-analysis. Eur Eat Disord Rev. permitted by statutory regulation or exceeds the permitted use, you will 2022;30(2):85–95. https:// doi. org/ 10. 1002/ erv. 2878. A recent need to obtain permission directly from the copyright holder. 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Current Addiction Reports – Springer Journals
Published: Dec 1, 2022
Keywords: Food addiction; Eating addiction; Ultra-processed food addiction; Loss of control; Craving
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