Emerging Trends in The Social and Behavioral Sciences

Emerging Evidence of Addiction in Problematic Eating Behavior

Item

Title

Emerging Evidence of Addiction in Problematic Eating Behavior

Author

Gearhardt, Ashley

Murray, Susan

Avena, Nicole M.

Research Area

Psychopathology

Topic

Mental Disorder Varieties

Abstract

Obesity continues to be a pressing global health crisis with few nonsurgical means of long‐term successful treatment. In addition, in the last year, binge eating disorder (BED), which shares several behavioral characteristics with traditional substance use disorders, has been recognized in the DSM‐V as a distinct eating disorder diagnosis. In light of such trends, an emerging and controversial hypothesis is that an addictive response to certain types of foods may be contributing to eating‐related problems. If certain individuals are experiencing an addiction to highly palatable foods, the treatment and prevention of problematic eating may need to be altered in such circumstances. Further, if certain food (or ingredients in food) are identified as having an addictive potential, policy approaches employed to reduce the public health impact of other types of addictive substances (e.g., reducing advertising to minors, taxation) may be of use in the obesity epidemic. In the following piece, we will review the research linking addiction and eating, but most importantly, we will identify directions for future research in this relatively new field of study.

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Identifier

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extracted text

Emerging Evidence of Addiction
in Problematic Eating Behavior
ASHLEY GEARHARDT, SUSAN MURRAY, and NICOLE M. AVENA

Abstract
Obesity continues to be a pressing global health crisis with few nonsurgical means
of long-term successful treatment. In addition, in the last year, binge eating disorder (BED), which shares several behavioral characteristics with traditional substance
use disorders, has been recognized in the DSM-V as a distinct eating disorder diagnosis. In light of such trends, an emerging and controversial hypothesis is that an
addictive response to certain types of foods may be contributing to eating-related
problems. If certain individuals are experiencing an addiction to highly palatable
foods, the treatment and prevention of problematic eating may need to be altered
in such circumstances. Further, if certain food (or ingredients in food) are identified
as having an addictive potential, policy approaches employed to reduce the public
health impact of other types of addictive substances (e.g., reducing advertising to
minors, taxation) may be of use in the obesity epidemic. In the following piece, we
will review the research linking addiction and eating, but most importantly, we will
identify directions for future research in this relatively new field of study.

FOUNDATIONAL RESEARCH
The food environment that we live in has changed dramatically over the past
several decades. Ultraprocessed, highly palatable food stuffs are cheap, easily accessible and heavily marketed. The addition of higher levels of sugar
has been one of the major drivers of this change, along with increased levels
of fat, salt, refined flours, and food additives. Hyperpalatable food, such as
ice cream, cookies, cakes and candy, exceed the level of reward associated
with more natural, minimally processed food, such as vegetables, fruits, and
nuts. The rising rates of obesity and recent recognition of BED (binge eating
disorder) as a distinct diagnosis that have accompanied the influx of these
types of food have led to the hypothesis that hyper-palatable food may be
capable of triggering an addictive process.
Foods and drugs of abuse both activate the neurotransmitter dopamine,
which has been implicated in reward processes. Further, increased food
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

palatability appears to be associated with a more marked activation of
the reward system (Volkow, Wang, Fowler, & Telang, 2008). Obesity and
substance dependence share certain neural underpinnings, such as increased
activation in motivation-related brain regions in response to cues and diminished activation in reward regions in response to consumption (Volkow
et al., 2002, 2008). BED also shares significant overlap with addiction. The
diagnostic criteria for BED and substance dependence include a number of
similar characteristics, such as diminished control over consumption and
continued use despite negative consequences (Volkow, Wang, Tomasi, &
Baler, 2013). Study participants with BED also appear to exhibit potential
dysfunction in neural regions implicated in executive control and reward
processing relative to healthy controls (Balodis et al., 2013; Wang et al., 2011;
Weygandt, Schaefer, Schienle, & Haynes, 2012), a pattern that has also been
noted in addictive disorders. These findings raise the possibility that similar
to addictive disorders, the diminished control over food consumption associated with BED may be related to neural differences in regions implicated
in executive control and reward processing. Thus, it has been suggested that
these parallels may reflect the role of an addictive-like process in obesity
and binge eating.
RECENT RESEARCH
ANIMAL MODEL RESEARCH
Intriguing animal model research suggests that certain food stuffs or ingredients may be capable of triggering an addictive process. Rats maintained on a
limited access schedule to a sugar solution exhibit several behaviors that are
commonly associated with substance dependence. For example, these animals tend to show larger and fewer eating episodes than controls, which is
thought to reflect “bingeing” (Avena, Rada, & Hoebel, 2008). Further, after
a period of abstinence, these animals show a marked increase in responding for sugar, which is considered an indication of craving (Avena, Long, &
Hoebel, 2005). When administered an opioid antagonist, which blocks opioid
receptors, or fasted from all food for 36 h, these animals also show evidence
of opiate-like withdrawal, including teeth chattering, forepaw tremors, and
head shakes (Avena, Bocarsly, Rada, Kim, & Hoebel, 2008; Colantuoni et al.,
2002). In addition, Oswald, Murdaugh, King, and Boggiano (2011) found that
rats prone to binge eating will endure greater magnitudes of electric shock
to obtain palatable food than those resistant to binge eating. Further, unlike
rats with no access or 1 h/day access to a cafeteria diet consisting of various meats, cakes, frosting, and chocolate, rats with extended access (18–23
h/day) to this diet do not decrease their intake of palatable food when shown

Emerging Evidence of Addiction in Problematic Eating Behavior

3

a stimulus associated with a foot shock (Johnson & Kenny, 2010). These two
findings provide evidence that such animals will pursue the reward associated with palatable food consumption despite adverse consequences. Recent
research has also shown that rats prefer a sucrose solution to both cocaine and
heroin when given the option to press a lever associated with each (Madsen
& Ahmed, 2014).
These behavioral indices of addiction are accompanied by neurochemical
alterations. For example, sugar consumption has been shown to repeatedly
increase dopamine within the nucleus accumbens, a brain region associated
with reward, of rats given intermittent sugar and chow access (Rada, Avena,
& Hoebel, 2005). In contrast, although rats given intermittent chow access
show an initial spike in dopamine, over time, this response decreases. However, rats with intermittent sugar and chow access continue to release high
levels of dopamine when given sugar, which reflects the pattern seen with
morphine administration (Pothos, Rada, Mark, & Hoebel, 1991). In addition,
Johnson and Kenny (2010) have found that rats with extended access to
the cafeteria diet mentioned above show a decrease in a type of dopamine
receptor (D2 receptors) within the striatum compared to control groups.
This is noteworthy as a number of studies have shown reduced striatal D2
receptors among individuals with substance dependence disorders (Fehr
et al., 2008). Further, rats that were genetically modified to have less striatal
D2 receptors demonstrate increased reward thresholds, suggesting that they
require greater stimulation to experience reward (Johnson & Kenny, 2010).
Findings such as these indicate underlying neurochemical abnormalities
that may result from and/or perpetuate addictive behaviors regarding
food.
HUMAN RESEARCH
Although there are strong parallels in brain regions that encode reward from
drugs and palatable food and in neural abnormalities associated with substance dependence and obesity/BED, these findings may tell us little about
true “food addiction.” Obesity is often linked to excess food consumption,
but other factors can contribute to unhealthy weight gain, including physical inactivity, medication side effects, and metabolic conditions. In addition,
excess consumption of a substance is not necessarily indicative of substance
dependence, or an “addiction.” For example, 40% of college students are
reported to binge drink (O’Malley & Johnston, 2002), but only 6% meet criteria for alcohol dependence (Knight et al., 2002). Further, addictive disorders
are typically diagnosed in the presence of certain behavioral indicators (e.g.,
loss of control, continued use despite negative consequences) (Table 1). Thus,

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Table 1
Diagnostic Criteria for Substance Dependence as Stated in the
DSM-IV-TR (APA, 2000)
1. Tolerance, as defined by either of the following:
a. The need for markedly increased amounts of the substance to achieve
intoxication or desired effect
b. Markedly diminished effect with continued use of the same amount of the
substance
2. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the substance
b. The same (or closely related) substance is taken to relieve or avoid withdrawal
symptoms
3. Taking the substance often in larger amounts or over a longer period than was
intended
4. There is a persistent desire or unsuccessful effort to cut down or control substance
use
5. Spending a great deal of time in activities necessary to obtain or use the substance or
to recover from its effects
6. Giving up social, occupational, or recreational activities because of substance use
7. Continuing the substance use with the knowledge that it is causing or exacerbating a
persistent or recurrent physical or psychological problem

when assessing food addiction, it would be useful to identify individuals
who exhibit similar signs of addiction with respect to their eating behavior
in addition to observing neural responses to food cues and receipt.
The Yale Food Addiction Scale (YFAS) was developed to operationalize
the construct of palatable food dependence (Gearhardt, Corbin, & Brownell,
2009) based on the DSM-IV-TR substance dependence criteria (APA, 2000).
A recent study found that the risk of YFAS “food addiction” increased with
obesity status and the severity of addictive-like eating was positively related
to measures of adiposity [e.g., body fat, BMI (body mass index)] (Pedram
et al., 2013). Further, addictive-like eating, as measured by the YFAS, has
been associated with a higher likelihood of a composite index of elevated
dopamine signaling (Davis et al., 2013), as well as a greater severity of
disordered eating (Gearhardt et al., 2012). In addition, when anticipating
food receipt, higher YFAS scores have been related to increased activation
of brain regions associated with craving and the motivation to eat, which
may resemble elevated motivation elicited by cues in addicted populations
(Gearhardt et al., 2011). Also akin to addictive disorders, this study found
an association between higher YFAS scores and reduced activation in
neural regions implicated in inhibitory control during palatable food receipt
(Gearhardt et al., 2011). Notably, the high and low “food addiction” groups
in this study did not differ by BMI and the results of the study remained

Emerging Evidence of Addiction in Problematic Eating Behavior

5

the same even after controlling for body weight. Therefore, behavioral
indicators of addictive-like eating are related to neural activation implicated
in addictive disorders even apart from the possible effects of elevated body
weight. This finding highlights the importance of viewing BMI and “food
addiction” as separate with overlap in certain cases.
Similarly, BED and YFAS “food addiction” are related to one another but
there also appear to be distinctions between the two. Approximately fifty
percent of obese patients diagnosed with BED meet the “food addiction”
threshold (Gearhardt, White, Masheb, & Grilo, 2013; Gearhardt et al., 2012),
which suggests that not all BED patients endorse addictive-like eating. In
BED patients, elevated YFAS scores are related to more frequent binge eating
episodes, elevated emotion dysregulation, and increased eating pathology
(Davis, 2013; Gearhardt et al., 2012, 2013). Thus, “food addiction” may be
associated with more severe pathology in the context of BED (Gearhardt et al.,
2012; Gearhardt, Roberto, Seamans, Corbin, & Brownell, 2013), perhaps making it more difficult to treat. This is consistent with prior research suggesting
that a BED diagnosis does not reflect a homogenous group, but rather that
there are subtypes within the diagnosis. One BED subtype is indicated by
high-levels of dietary restraint while another exhibits greater negative affect,
impulsivity, and overall pathology (Grilo, Masheb, & Wilson, 2001; Stice et al.,
2001). These two subtypes of BED could potentially be driven by different
mechanisms, with an addictive process possibly associated with the latter
subtype but not the former.
KEY ISSUES FOR FUTURE RESEARCH
Although there has been substantial progress in the study of addictive-like
eating, this is a relatively new area of research and there are still more questions than answers. One of the most important areas for future research is to
examine what types of food or components of food may be capable of triggering an addictive process. Especially in the human literature, the vast majority of research has focused on who may be experiencing an addictive-like
response to food, but less attention has been paid to identifying the possible
addictive ingredients of food. The identification of the addictive agent will
provide important information about the mechanisms driving compulsive
eating. It is clear that all food stuffs are not equal in their ability to trigger
addictive-like eating. For example, it is very rare for someone to report binging on broccoli or eating chicken breasts until they are uncomfortably full. In
contrast, food rich in added sugars, refined carbohydrates, and/or fats (e.g.,
candy, chocolate, French fries, cheese burgers, and pasta), are much more
likely to be described as problematic. At this point, sugar has been identified
as the most likely culprit in eliciting addictive behaviors based on findings

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

from animal models and some neuroimaging research (Avena, Rada, et al.,
2008; Stice, Burger, & Yokum, 2013). However, many of the food stuffs that
seem to induce cravings and loss of control contain ingredients other than
sugar (e.g., fat, other refined carbohydrates, salt), indicating a need for further research in this area. In addition, it may be beneficial to assess possible
interactions between ingredients.
A better understanding of which types of food or ingredients tend to result
in addictive behaviors may also inform policy and treatment approaches.
The greatest tobacco-related public health gains were made when policy
approaches altered the price and access to cigarettes, as well as other nicotine
products, and the companies creating and marketing these products became
more culpable. If certain food stuffs are identified as addictive, this may
be helpful in understanding the specific ways in which our environment
encourages excessive consumption of these food stuffs and identifying
effective targets for policy interventions. For example, food marketing is
a major source of cues for potentially addictive food stuffs in our environment and the industry spends millions of dollars to ensure that these
advertising campaigns are effective. Recent research has identified that food
commercials, relative to other types of commercials, are more effective in
triggering reward circuitry in the brains of adolescents (Gearhardt, Yokum,
Stice, Harris & Brownell, 2014). If certain food stuffs are found to be capable
of triggering an addictive response, this may inform policy debates about
restricting the advertising of these products, especially to children.
There are also a number of treatment implications of “food addiction” that
are yet to be explored. One commonly held approach in the treatment of
eating-related problems is that there are no “good” or “bad” types of food.
For individuals struggling with overeating highly palatable food, the implicit
message is that their struggles are a result of deficiencies in their willpower.
Although there are certainly individual differences that may increase the
risk of overeating, there are also likely properties of certain food stuffs that
differentially activate the reward system and may perpetuate compulsive
eating. One of the most controversial implications of the addiction construct
is that some individuals may benefit from the elimination of certain types
offood from their diet, similar to the elimination of alcohol for individuals
with alcohol use disorders. This raises concerns from other perspectives,
including the fear that this increase in dietary restraint may backfire and
trigger more disordered eating (Polivy, 1996). Although support for the
restraint hypothesis of disordered eating is mixed, this is a valid concern
and a research topic that needs to be examined empirically, particularly
among those who met the criteria for a “food addiction.” For example,
it may be insightful to examine the outcomes of existing programs that
employ an abstinence approach to kinds of certain food, such as Overeaters

Emerging Evidence of Addiction in Problematic Eating Behavior

7

Anonymous and Food Addicts Anonymous. Other aspects of addiction
treatment are consistent with traditional approaches to treating problematic
eating behaviors and many addiction-related strategies are already being
implemented in eating-focused interventions, such as identifying triggers,
coping with cravings, developing alternative ways to cope with negative
emotions, motivational interviewing and relapse prevention (Gearhardt,
White, & Potenza, 2011; von Ranson & Robinson, 2006).
To increase the effectiveness of these intervention approaches and to more
appropriately evaluate the “food addiction” hypothesis, it will be important
to identify phenotypes that reflect addictive-like eating rather than using
rough proxies. As mentioned previously, obesity has been frequently
used as a proxy for addictive eating and critics of the “food addiction”
hypothesis point out that the neurobiological parallels between obesity
and addiction are somewhat inconsistent (Ziauddeen, Farooqi, & Fletcher,
2012). Yet, obesity is a heterogeneous condition and it is highly unlikely
that all obesity results from “food addiction.” Further, not all individuals
with a healthy BMI have a normal relationship with food. Thus, the use
of weight status to indicate addictive-like eating likely results in both the
over- and under-identification of “food addicts,” which may contribute to
discrepancies in the literature (Avena, Gearhardt, Gold, Wang, & Potenza,
2012). Developing a better understanding of the subtypes of individuals
most prone to addictive-eating behavior will be essential to more precisely
examine whether addictive mechanisms are truly contributing to problematic eating and to match patients to the most appropriate treatment.
The YFAS is one tool that attempts to classify this subtype but further
evaluation is needed and additional tools, such as clinical interviews, may
be warranted.
Further, certain mechanisms implicated in addiction have received little
empirical evaluation regarding their role in problematic eating. Tolerance
and withdrawal are key indicators of physiological dependence to an addictive substance. Although neither of these criteria is required for a diagnosis of substance dependence, tolerance and withdrawal are often considered
key characteristics of addiction. Reviews critical of the validity of the food
addiction construct will state that there is no evidence of withdrawal or tolerance with such eating behaviors (Drewnowski & Bellisle, 2007; Wilson, 2010;
Ziauddeen et al., 2012), but this is premature given the marked lack of studies
in the area and the evidence for withdrawal and tolerance to sugar demonstrated in animal models. In one of the only studies on this topic in humans,
Spring et al. (2008) found that after repeated administrations, carbohydrate
cravers exhibited tolerance to the pleasant affective consequences of consuming a carbohydrate-rich shake (compared to a placebo shake). Regarding
withdrawal, there have been anecdotal reports of headaches, irritability, sleep

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

disturbance, chills and low mood among dieters cutting down on refined carbohydrates (Atkins, 2002). Empirical research is needed to explore whether
behavioral, biological, and psychological indicators of withdrawal and tolerance are present among humans who report problematic eating behavior,
and if certain types of food are more likely to trigger these responses than
others.
Finally, little is known about the role that addictive-like eating may play
in childhood obesity. In the substance dependence literature, an earlier age
of exposure to addictive substances (e.g., alcohol, nicotine) is implicated
in risk for the development of future problematic substance use (DeWit,
Adlaf, Offord, & Ogborne, 2000). This risk may result from adaptations in
a vulnerable neural system (Tapert, Caldwell, & Burke, 2005), as well as
an increased likelihood to use substances to cope psychologically (Clark,
Thatcher, & Tapert, 2008). If certain types of food also have addictive
potential, children may be especially susceptible to this effect as a result of
neural and psychological vulnerabilities.
There is some evidence to suggest that addictive processes may be at
play in problematic eating behavior in children. In a qualitative study of
overweight/obese 8–21 year olds, behaviors consistent with addiction (e.g.,
tolerance, cravings) were frequently described and 66% identified addiction
as a contributor to their eating problems (Pretlow, 2011). In addition, 15.2%
of children receiving treatment at a pediatric lipid clinic reported that they
often, usually, or always felt addicted to food and reports of addictive
eating were related to more significant eating problems (Merlo, Klingman,
Malasanos, & Silverstein, 2009). Recently, the YFAS was adapted to be
administered to children. Elevated scores on this measure were associated with greater BMI. Further, children with higher YFAS scores were
more likely to emotionally eat and to be less responsive to satiety signals
(Gearhardt et al., 2013). An important area of future research is to examine
whether neurobiological parallels to addiction are seen in children who
report addictive-like eating behaviors. In addition, animal models suggest
that addictive-like consumption of sugar increases the propensity to be
sensitized to other drugs of abuse (Avena, Carrillo, Needham, Leibowitz, &
Hoebel, 2004; Avena & Hoebel, 2003). Thus, it will be important to examine
whether addictive-like eating patterns early in development increase the
likelihood for future problems with drugs of abuse.
Accumulating evidence suggests that addictive processes marked by
behavioral changes and brain adaptations may develop in response to
palatable food and beverage consumption. Further research is needed,
however, to more fully understand the specific components of such food
and beverages that may contribute to addiction-like symptoms. In addition,

Emerging Evidence of Addiction in Problematic Eating Behavior

9

further study is needed to explore and characterize certain features of addiction, such as tolerance and withdrawal, among human samples. Finally, it is
critical to begin assessing the effects of palatable food consumption during
vulnerable periods of development, such as childhood and adolescence.
With progress in these areas, this emerging field of research may lend
practical insight into the public health and psychological issues of both
binge eating behavior and obesity.
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23–39.
Oswald, K. D., Murdaugh, D. L., King, V. L., & Boggiano, M. M. (2011). Motivation
for palatable food despite consequences in an animal model of binge eating. International Journal of Eating Disorders, 44(3), 203–211.
Pedram, P, Wadden, D, Amini, P, Gulliver, W, Randell, E, Cahill, Fa, … Zhai, G.
(2013). Food addiction: Its prevalence and significant association with obesity in
the general population. PLoS One, 8(9), e74832.
Polivy, J. (1996). Psychological consequences of food restriction. Journal of the American Dietetic Association, 96(6), 589–592.
Pothos, E., Rada, P., Mark, G. P., & Hoebel, B. G. (1991). Dopamine microdialysis in the nucleus accumbens during acute and chronic morphine, naloxone-precipitated withdrawal and clonidine treatment. Brain Research, 566(1–2), 348–350.
Pretlow, R. A. (2011). Addiction to highly pleasurable food as a cause of the
childhood obesity epidemic: A qualitative internet study. Eating Disorders, 19(4),
295–307.
Rada, P., Avena, N. M., & Hoebel, B. G. (2005). Daily bingeing on sugar repeatedly
releases dopamine in the accumbens shell. Neuroscience, 134(3), 737–744.
Spring, B., Schneider, K., Smith, M., Kendzor, D., Appelhans, B., Hedeker, D., &
Pagoto, S. (2008). Abuse potential of carbohydrates for overweight carbohydrate
cravers. Psychopharmacology, 197(4), 637–647.
Stice, E., Agras, W. S., Telch, C. F., Halmi, K. A., Mitchell, J. E., & Wilson, T. (2001). Subtyping binge eating-disordered women along dieting and negative affect dimensions. International Journal of Eating Disorders, 30(1), 11–27.
Stice, E., Burger, K. S., & Yokum, S. (2013). Relative ability of fat and sugar tastes to
activate reward, gustatory, and somatosensory regions. American Journal of Clinical
Nutrition, 98(6), 1377–1384.
Tapert, S. F., Caldwell, L., & Burke, C. (2005). Alcohol and the adolescent brain:
Human studies. Alcohol Research & Health, 28, 205–212.
Volkow, N. D., Wang, G. J., Fowler, J. S., Logan, J., Jayne, M., Franceschi, D., … Pappas, N. (2002). "Nonhedonic" food motivation in humans involves dopamine in the
dorsal striatum and methylphenidate amplifies this effect. Synapse, 44(3), 175–180.
Volkow, N. D., Wang, G. J., Fowler, J. S., & Telang, F. (2008). Overlapping neuronal circuits in addiction and obesity: evidence of systems pathology. Philosophical Transactions of the Royal Society, B: Biological Sciences, 363(1507), 3191–3200.
Volkow, N. D., Wang, G. J., Tomasi, D., & Baler, R. D. (2013). Obesity and addiction:
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von Ranson, K. M., & Robinson, K. E. (2006). Who is providing what type of psychotherapy to eating disorder clients? A survey. International Journal of Eating Disorders, 39(1), 27–34.
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Weygandt, M., Schaefer, A., Schienle, A., & Haynes, J. D. (2012). Diagnosing different
binge-eating disorders based on reward-related brain activation patterns. Human
Brain Mapping, 33(9), 2135–2146.
Wilson, G. T. (2010). Eating disorders, obesity and addiction. European Eating Disorders Review, 18(5), 341–351.
Ziauddeen, H., Farooqi, I. S., & Fletcher, P. C. (2012). Obesity and the brain: How
convincing is the addiction model? Nature Reviews Neuroscience, 13(4), 279–286.

ASHLEY GEARHARDT SHORT BIOGRAPHY
Ashley Gearhardt, PhD, is an Assistant Professor of Clinical Psychology
at the University of Michigan. While working on her doctorate in clinical
psychology at Yale University, Dr. Gearhardt became interested in the
possibility that certain food stuffs may be capable of triggering an addictive
process. To explore this further, she developed the Yale Food Addiction
Scale (YFAS) to operationalize addictive-like eating behaviors. Scores on this
scale have recently been linked with more frequent binge eating episodes
in clinical populations, increased prevalence of obesity and patterns of
neural activation implicated in other addictive behaviors. Dr. Gearhardt
also investigates the impact of certain components of the food environment,
such as food advertising, on obesity risk through the use of multi-method
approaches (e.g., neuroimaging, eye tracking). She is currently the director
of the Food and Addiction Science and Treatment (FAST) lab to further
evaluate whether addictive-like mechanisms contribute to certain types of
problematic eating behavior. Web site: http://fastlab.psych.lsa.umich.edu/
SUSAN MURRAY SHORT BIOGRAPHY
Susan Murray is currently a research assistant in Dr. Nicole Avena’s laboratory at the Icahn School of Medicine, Mount Sinai. Susan received a BS in psychology from Fordham University in 2012. Her academic interests include
the study of eating disorders, obesity, and coping mechanisms. She has published five articles in scholarly journals and two book chapters on topics
related to the neural correlates of under- and overeating, obesity, and food
addiction.
NICOLE M. AVENA SHORT BIOGRAPHY
Dr. Nicole M. Avena is a research psychologist and neuroscientist with interests in the fields of nutrition, diet and addiction. She received a PhD in Psychology and Neuroscience from Princeton University in 2006, followed by a
postdoctoral fellowship at Rockefeller University. Dr. Avena presently holds

Emerging Evidence of Addiction in Problematic Eating Behavior

13

a faculty position in the Department of Pharmacology and Systems Therapeutics at the Icahn School of Medicine, Mount Sinai. She has published over
60 scholarly journal articles on topics related to diet, nutrition and overeating. Her research achievements have been honored by awards from groups
including the New York Academy of Sciences, the American Psychological
Association, and the National Institute on Drug Abuse.
Dr. Avena has a website www.DrNicoleAvena.com, a blog on Psychology
Today, and you can also follow her on Twitter or Facebook.

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G. Harvey
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et al.
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Social Classification (Sociology), Elizabeth G. Pontikes

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
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Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.



Emerging Evidence of Addiction
in Problematic Eating Behavior
ASHLEY GEARHARDT, SUSAN MURRAY, and NICOLE M. AVENA

Abstract
Obesity continues to be a pressing global health crisis with few nonsurgical means
of long-term successful treatment. In addition, in the last year, binge eating disorder (BED), which shares several behavioral characteristics with traditional substance
use disorders, has been recognized in the DSM-V as a distinct eating disorder diagnosis. In light of such trends, an emerging and controversial hypothesis is that an
addictive response to certain types of foods may be contributing to eating-related
problems. If certain individuals are experiencing an addiction to highly palatable
foods, the treatment and prevention of problematic eating may need to be altered
in such circumstances. Further, if certain food (or ingredients in food) are identified
as having an addictive potential, policy approaches employed to reduce the public
health impact of other types of addictive substances (e.g., reducing advertising to
minors, taxation) may be of use in the obesity epidemic. In the following piece, we
will review the research linking addiction and eating, but most importantly, we will
identify directions for future research in this relatively new field of study.

FOUNDATIONAL RESEARCH
The food environment that we live in has changed dramatically over the past
several decades. Ultraprocessed, highly palatable food stuffs are cheap, easily accessible and heavily marketed. The addition of higher levels of sugar
has been one of the major drivers of this change, along with increased levels
of fat, salt, refined flours, and food additives. Hyperpalatable food, such as
ice cream, cookies, cakes and candy, exceed the level of reward associated
with more natural, minimally processed food, such as vegetables, fruits, and
nuts. The rising rates of obesity and recent recognition of BED (binge eating
disorder) as a distinct diagnosis that have accompanied the influx of these
types of food have led to the hypothesis that hyper-palatable food may be
capable of triggering an addictive process.
Foods and drugs of abuse both activate the neurotransmitter dopamine,
which has been implicated in reward processes. Further, increased food
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

palatability appears to be associated with a more marked activation of
the reward system (Volkow, Wang, Fowler, & Telang, 2008). Obesity and
substance dependence share certain neural underpinnings, such as increased
activation in motivation-related brain regions in response to cues and diminished activation in reward regions in response to consumption (Volkow
et al., 2002, 2008). BED also shares significant overlap with addiction. The
diagnostic criteria for BED and substance dependence include a number of
similar characteristics, such as diminished control over consumption and
continued use despite negative consequences (Volkow, Wang, Tomasi, &
Baler, 2013). Study participants with BED also appear to exhibit potential
dysfunction in neural regions implicated in executive control and reward
processing relative to healthy controls (Balodis et al., 2013; Wang et al., 2011;
Weygandt, Schaefer, Schienle, & Haynes, 2012), a pattern that has also been
noted in addictive disorders. These findings raise the possibility that similar
to addictive disorders, the diminished control over food consumption associated with BED may be related to neural differences in regions implicated
in executive control and reward processing. Thus, it has been suggested that
these parallels may reflect the role of an addictive-like process in obesity
and binge eating.
RECENT RESEARCH
ANIMAL MODEL RESEARCH
Intriguing animal model research suggests that certain food stuffs or ingredients may be capable of triggering an addictive process. Rats maintained on a
limited access schedule to a sugar solution exhibit several behaviors that are
commonly associated with substance dependence. For example, these animals tend to show larger and fewer eating episodes than controls, which is
thought to reflect “bingeing” (Avena, Rada, & Hoebel, 2008). Further, after
a period of abstinence, these animals show a marked increase in responding for sugar, which is considered an indication of craving (Avena, Long, &
Hoebel, 2005). When administered an opioid antagonist, which blocks opioid
receptors, or fasted from all food for 36 h, these animals also show evidence
of opiate-like withdrawal, including teeth chattering, forepaw tremors, and
head shakes (Avena, Bocarsly, Rada, Kim, & Hoebel, 2008; Colantuoni et al.,
2002). In addition, Oswald, Murdaugh, King, and Boggiano (2011) found that
rats prone to binge eating will endure greater magnitudes of electric shock
to obtain palatable food than those resistant to binge eating. Further, unlike
rats with no access or 1 h/day access to a cafeteria diet consisting of various meats, cakes, frosting, and chocolate, rats with extended access (18–23
h/day) to this diet do not decrease their intake of palatable food when shown

Emerging Evidence of Addiction in Problematic Eating Behavior

3

a stimulus associated with a foot shock (Johnson & Kenny, 2010). These two
findings provide evidence that such animals will pursue the reward associated with palatable food consumption despite adverse consequences. Recent
research has also shown that rats prefer a sucrose solution to both cocaine and
heroin when given the option to press a lever associated with each (Madsen
& Ahmed, 2014).
These behavioral indices of addiction are accompanied by neurochemical
alterations. For example, sugar consumption has been shown to repeatedly
increase dopamine within the nucleus accumbens, a brain region associated
with reward, of rats given intermittent sugar and chow access (Rada, Avena,
& Hoebel, 2005). In contrast, although rats given intermittent chow access
show an initial spike in dopamine, over time, this response decreases. However, rats with intermittent sugar and chow access continue to release high
levels of dopamine when given sugar, which reflects the pattern seen with
morphine administration (Pothos, Rada, Mark, & Hoebel, 1991). In addition,
Johnson and Kenny (2010) have found that rats with extended access to
the cafeteria diet mentioned above show a decrease in a type of dopamine
receptor (D2 receptors) within the striatum compared to control groups.
This is noteworthy as a number of studies have shown reduced striatal D2
receptors among individuals with substance dependence disorders (Fehr
et al., 2008). Further, rats that were genetically modified to have less striatal
D2 receptors demonstrate increased reward thresholds, suggesting that they
require greater stimulation to experience reward (Johnson & Kenny, 2010).
Findings such as these indicate underlying neurochemical abnormalities
that may result from and/or perpetuate addictive behaviors regarding
food.
HUMAN RESEARCH
Although there are strong parallels in brain regions that encode reward from
drugs and palatable food and in neural abnormalities associated with substance dependence and obesity/BED, these findings may tell us little about
true “food addiction.” Obesity is often linked to excess food consumption,
but other factors can contribute to unhealthy weight gain, including physical inactivity, medication side effects, and metabolic conditions. In addition,
excess consumption of a substance is not necessarily indicative of substance
dependence, or an “addiction.” For example, 40% of college students are
reported to binge drink (O’Malley & Johnston, 2002), but only 6% meet criteria for alcohol dependence (Knight et al., 2002). Further, addictive disorders
are typically diagnosed in the presence of certain behavioral indicators (e.g.,
loss of control, continued use despite negative consequences) (Table 1). Thus,

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Table 1
Diagnostic Criteria for Substance Dependence as Stated in the
DSM-IV-TR (APA, 2000)
1. Tolerance, as defined by either of the following:
a. The need for markedly increased amounts of the substance to achieve
intoxication or desired effect
b. Markedly diminished effect with continued use of the same amount of the
substance
2. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the substance
b. The same (or closely related) substance is taken to relieve or avoid withdrawal
symptoms
3. Taking the substance often in larger amounts or over a longer period than was
intended
4. There is a persistent desire or unsuccessful effort to cut down or control substance
use
5. Spending a great deal of time in activities necessary to obtain or use the substance or
to recover from its effects
6. Giving up social, occupational, or recreational activities because of substance use
7. Continuing the substance use with the knowledge that it is causing or exacerbating a
persistent or recurrent physical or psychological problem

when assessing food addiction, it would be useful to identify individuals
who exhibit similar signs of addiction with respect to their eating behavior
in addition to observing neural responses to food cues and receipt.
The Yale Food Addiction Scale (YFAS) was developed to operationalize
the construct of palatable food dependence (Gearhardt, Corbin, & Brownell,
2009) based on the DSM-IV-TR substance dependence criteria (APA, 2000).
A recent study found that the risk of YFAS “food addiction” increased with
obesity status and the severity of addictive-like eating was positively related
to measures of adiposity [e.g., body fat, BMI (body mass index)] (Pedram
et al., 2013). Further, addictive-like eating, as measured by the YFAS, has
been associated with a higher likelihood of a composite index of elevated
dopamine signaling (Davis et al., 2013), as well as a greater severity of
disordered eating (Gearhardt et al., 2012). In addition, when anticipating
food receipt, higher YFAS scores have been related to increased activation
of brain regions associated with craving and the motivation to eat, which
may resemble elevated motivation elicited by cues in addicted populations
(Gearhardt et al., 2011). Also akin to addictive disorders, this study found
an association between higher YFAS scores and reduced activation in
neural regions implicated in inhibitory control during palatable food receipt
(Gearhardt et al., 2011). Notably, the high and low “food addiction” groups
in this study did not differ by BMI and the results of the study remained

Emerging Evidence of Addiction in Problematic Eating Behavior

5

the same even after controlling for body weight. Therefore, behavioral
indicators of addictive-like eating are related to neural activation implicated
in addictive disorders even apart from the possible effects of elevated body
weight. This finding highlights the importance of viewing BMI and “food
addiction” as separate with overlap in certain cases.
Similarly, BED and YFAS “food addiction” are related to one another but
there also appear to be distinctions between the two. Approximately fifty
percent of obese patients diagnosed with BED meet the “food addiction”
threshold (Gearhardt, White, Masheb, & Grilo, 2013; Gearhardt et al., 2012),
which suggests that not all BED patients endorse addictive-like eating. In
BED patients, elevated YFAS scores are related to more frequent binge eating
episodes, elevated emotion dysregulation, and increased eating pathology
(Davis, 2013; Gearhardt et al., 2012, 2013). Thus, “food addiction” may be
associated with more severe pathology in the context of BED (Gearhardt et al.,
2012; Gearhardt, Roberto, Seamans, Corbin, & Brownell, 2013), perhaps making it more difficult to treat. This is consistent with prior research suggesting
that a BED diagnosis does not reflect a homogenous group, but rather that
there are subtypes within the diagnosis. One BED subtype is indicated by
high-levels of dietary restraint while another exhibits greater negative affect,
impulsivity, and overall pathology (Grilo, Masheb, & Wilson, 2001; Stice et al.,
2001). These two subtypes of BED could potentially be driven by different
mechanisms, with an addictive process possibly associated with the latter
subtype but not the former.
KEY ISSUES FOR FUTURE RESEARCH
Although there has been substantial progress in the study of addictive-like
eating, this is a relatively new area of research and there are still more questions than answers. One of the most important areas for future research is to
examine what types of food or components of food may be capable of triggering an addictive process. Especially in the human literature, the vast majority of research has focused on who may be experiencing an addictive-like
response to food, but less attention has been paid to identifying the possible
addictive ingredients of food. The identification of the addictive agent will
provide important information about the mechanisms driving compulsive
eating. It is clear that all food stuffs are not equal in their ability to trigger
addictive-like eating. For example, it is very rare for someone to report binging on broccoli or eating chicken breasts until they are uncomfortably full. In
contrast, food rich in added sugars, refined carbohydrates, and/or fats (e.g.,
candy, chocolate, French fries, cheese burgers, and pasta), are much more
likely to be described as problematic. At this point, sugar has been identified
as the most likely culprit in eliciting addictive behaviors based on findings

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

from animal models and some neuroimaging research (Avena, Rada, et al.,
2008; Stice, Burger, & Yokum, 2013). However, many of the food stuffs that
seem to induce cravings and loss of control contain ingredients other than
sugar (e.g., fat, other refined carbohydrates, salt), indicating a need for further research in this area. In addition, it may be beneficial to assess possible
interactions between ingredients.
A better understanding of which types of food or ingredients tend to result
in addictive behaviors may also inform policy and treatment approaches.
The greatest tobacco-related public health gains were made when policy
approaches altered the price and access to cigarettes, as well as other nicotine
products, and the companies creating and marketing these products became
more culpable. If certain food stuffs are identified as addictive, this may
be helpful in understanding the specific ways in which our environment
encourages excessive consumption of these food stuffs and identifying
effective targets for policy interventions. For example, food marketing is
a major source of cues for potentially addictive food stuffs in our environment and the industry spends millions of dollars to ensure that these
advertising campaigns are effective. Recent research has identified that food
commercials, relative to other types of commercials, are more effective in
triggering reward circuitry in the brains of adolescents (Gearhardt, Yokum,
Stice, Harris & Brownell, 2014). If certain food stuffs are found to be capable
of triggering an addictive response, this may inform policy debates about
restricting the advertising of these products, especially to children.
There are also a number of treatment implications of “food addiction” that
are yet to be explored. One commonly held approach in the treatment of
eating-related problems is that there are no “good” or “bad” types of food.
For individuals struggling with overeating highly palatable food, the implicit
message is that their struggles are a result of deficiencies in their willpower.
Although there are certainly individual differences that may increase the
risk of overeating, there are also likely properties of certain food stuffs that
differentially activate the reward system and may perpetuate compulsive
eating. One of the most controversial implications of the addiction construct
is that some individuals may benefit from the elimination of certain types
offood from their diet, similar to the elimination of alcohol for individuals
with alcohol use disorders. This raises concerns from other perspectives,
including the fear that this increase in dietary restraint may backfire and
trigger more disordered eating (Polivy, 1996). Although support for the
restraint hypothesis of disordered eating is mixed, this is a valid concern
and a research topic that needs to be examined empirically, particularly
among those who met the criteria for a “food addiction.” For example,
it may be insightful to examine the outcomes of existing programs that
employ an abstinence approach to kinds of certain food, such as Overeaters

Emerging Evidence of Addiction in Problematic Eating Behavior

7

Anonymous and Food Addicts Anonymous. Other aspects of addiction
treatment are consistent with traditional approaches to treating problematic
eating behaviors and many addiction-related strategies are already being
implemented in eating-focused interventions, such as identifying triggers,
coping with cravings, developing alternative ways to cope with negative
emotions, motivational interviewing and relapse prevention (Gearhardt,
White, & Potenza, 2011; von Ranson & Robinson, 2006).
To increase the effectiveness of these intervention approaches and to more
appropriately evaluate the “food addiction” hypothesis, it will be important
to identify phenotypes that reflect addictive-like eating rather than using
rough proxies. As mentioned previously, obesity has been frequently
used as a proxy for addictive eating and critics of the “food addiction”
hypothesis point out that the neurobiological parallels between obesity
and addiction are somewhat inconsistent (Ziauddeen, Farooqi, & Fletcher,
2012). Yet, obesity is a heterogeneous condition and it is highly unlikely
that all obesity results from “food addiction.” Further, not all individuals
with a healthy BMI have a normal relationship with food. Thus, the use
of weight status to indicate addictive-like eating likely results in both the
over- and under-identification of “food addicts,” which may contribute to
discrepancies in the literature (Avena, Gearhardt, Gold, Wang, & Potenza,
2012). Developing a better understanding of the subtypes of individuals
most prone to addictive-eating behavior will be essential to more precisely
examine whether addictive mechanisms are truly contributing to problematic eating and to match patients to the most appropriate treatment.
The YFAS is one tool that attempts to classify this subtype but further
evaluation is needed and additional tools, such as clinical interviews, may
be warranted.
Further, certain mechanisms implicated in addiction have received little
empirical evaluation regarding their role in problematic eating. Tolerance
and withdrawal are key indicators of physiological dependence to an addictive substance. Although neither of these criteria is required for a diagnosis of substance dependence, tolerance and withdrawal are often considered
key characteristics of addiction. Reviews critical of the validity of the food
addiction construct will state that there is no evidence of withdrawal or tolerance with such eating behaviors (Drewnowski & Bellisle, 2007; Wilson, 2010;
Ziauddeen et al., 2012), but this is premature given the marked lack of studies
in the area and the evidence for withdrawal and tolerance to sugar demonstrated in animal models. In one of the only studies on this topic in humans,
Spring et al. (2008) found that after repeated administrations, carbohydrate
cravers exhibited tolerance to the pleasant affective consequences of consuming a carbohydrate-rich shake (compared to a placebo shake). Regarding
withdrawal, there have been anecdotal reports of headaches, irritability, sleep

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

disturbance, chills and low mood among dieters cutting down on refined carbohydrates (Atkins, 2002). Empirical research is needed to explore whether
behavioral, biological, and psychological indicators of withdrawal and tolerance are present among humans who report problematic eating behavior,
and if certain types of food are more likely to trigger these responses than
others.
Finally, little is known about the role that addictive-like eating may play
in childhood obesity. In the substance dependence literature, an earlier age
of exposure to addictive substances (e.g., alcohol, nicotine) is implicated
in risk for the development of future problematic substance use (DeWit,
Adlaf, Offord, & Ogborne, 2000). This risk may result from adaptations in
a vulnerable neural system (Tapert, Caldwell, & Burke, 2005), as well as
an increased likelihood to use substances to cope psychologically (Clark,
Thatcher, & Tapert, 2008). If certain types of food also have addictive
potential, children may be especially susceptible to this effect as a result of
neural and psychological vulnerabilities.
There is some evidence to suggest that addictive processes may be at
play in problematic eating behavior in children. In a qualitative study of
overweight/obese 8–21 year olds, behaviors consistent with addiction (e.g.,
tolerance, cravings) were frequently described and 66% identified addiction
as a contributor to their eating problems (Pretlow, 2011). In addition, 15.2%
of children receiving treatment at a pediatric lipid clinic reported that they
often, usually, or always felt addicted to food and reports of addictive
eating were related to more significant eating problems (Merlo, Klingman,
Malasanos, & Silverstein, 2009). Recently, the YFAS was adapted to be
administered to children. Elevated scores on this measure were associated with greater BMI. Further, children with higher YFAS scores were
more likely to emotionally eat and to be less responsive to satiety signals
(Gearhardt et al., 2013). An important area of future research is to examine
whether neurobiological parallels to addiction are seen in children who
report addictive-like eating behaviors. In addition, animal models suggest
that addictive-like consumption of sugar increases the propensity to be
sensitized to other drugs of abuse (Avena, Carrillo, Needham, Leibowitz, &
Hoebel, 2004; Avena & Hoebel, 2003). Thus, it will be important to examine
whether addictive-like eating patterns early in development increase the
likelihood for future problems with drugs of abuse.
Accumulating evidence suggests that addictive processes marked by
behavioral changes and brain adaptations may develop in response to
palatable food and beverage consumption. Further research is needed,
however, to more fully understand the specific components of such food
and beverages that may contribute to addiction-like symptoms. In addition,

Emerging Evidence of Addiction in Problematic Eating Behavior

9

further study is needed to explore and characterize certain features of addiction, such as tolerance and withdrawal, among human samples. Finally, it is
critical to begin assessing the effects of palatable food consumption during
vulnerable periods of development, such as childhood and adolescence.
With progress in these areas, this emerging field of research may lend
practical insight into the public health and psychological issues of both
binge eating behavior and obesity.
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American Psychiatric Association (2000). Diagnostic and statistical manual of mental
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Avena, N. M., Bocarsly, M. E., Rada, P., Kim, A., & Hoebel, B. G. (2008). After daily
bingeing on a sucrose solution, food deprivation induces anxiety and accumbens
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Avena, N. M., Carrillo, C. A., Needham, L., Leibowitz, S. F., & Hoebel, B. G. (2004).
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ASHLEY GEARHARDT SHORT BIOGRAPHY
Ashley Gearhardt, PhD, is an Assistant Professor of Clinical Psychology
at the University of Michigan. While working on her doctorate in clinical
psychology at Yale University, Dr. Gearhardt became interested in the
possibility that certain food stuffs may be capable of triggering an addictive
process. To explore this further, she developed the Yale Food Addiction
Scale (YFAS) to operationalize addictive-like eating behaviors. Scores on this
scale have recently been linked with more frequent binge eating episodes
in clinical populations, increased prevalence of obesity and patterns of
neural activation implicated in other addictive behaviors. Dr. Gearhardt
also investigates the impact of certain components of the food environment,
such as food advertising, on obesity risk through the use of multi-method
approaches (e.g., neuroimaging, eye tracking). She is currently the director
of the Food and Addiction Science and Treatment (FAST) lab to further
evaluate whether addictive-like mechanisms contribute to certain types of
problematic eating behavior. Web site: http://fastlab.psych.lsa.umich.edu/
SUSAN MURRAY SHORT BIOGRAPHY
Susan Murray is currently a research assistant in Dr. Nicole Avena’s laboratory at the Icahn School of Medicine, Mount Sinai. Susan received a BS in psychology from Fordham University in 2012. Her academic interests include
the study of eating disorders, obesity, and coping mechanisms. She has published five articles in scholarly journals and two book chapters on topics
related to the neural correlates of under- and overeating, obesity, and food
addiction.
NICOLE M. AVENA SHORT BIOGRAPHY
Dr. Nicole M. Avena is a research psychologist and neuroscientist with interests in the fields of nutrition, diet and addiction. She received a PhD in Psychology and Neuroscience from Princeton University in 2006, followed by a
postdoctoral fellowship at Rockefeller University. Dr. Avena presently holds

Emerging Evidence of Addiction in Problematic Eating Behavior

13

a faculty position in the Department of Pharmacology and Systems Therapeutics at the Icahn School of Medicine, Mount Sinai. She has published over
60 scholarly journal articles on topics related to diet, nutrition and overeating. Her research achievements have been honored by awards from groups
including the New York Academy of Sciences, the American Psychological
Association, and the National Institute on Drug Abuse.
Dr. Avena has a website www.DrNicoleAvena.com, a blog on Psychology
Today, and you can also follow her on Twitter or Facebook.

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Emerging Evidence of Addiction
in Problematic Eating Behavior
ASHLEY GEARHARDT, SUSAN MURRAY, and NICOLE M. AVENA

Abstract
Obesity continues to be a pressing global health crisis with few nonsurgical means
of long-term successful treatment. In addition, in the last year, binge eating disorder (BED), which shares several behavioral characteristics with traditional substance
use disorders, has been recognized in the DSM-V as a distinct eating disorder diagnosis. In light of such trends, an emerging and controversial hypothesis is that an
addictive response to certain types of foods may be contributing to eating-related
problems. If certain individuals are experiencing an addiction to highly palatable
foods, the treatment and prevention of problematic eating may need to be altered
in such circumstances. Further, if certain food (or ingredients in food) are identified
as having an addictive potential, policy approaches employed to reduce the public
health impact of other types of addictive substances (e.g., reducing advertising to
minors, taxation) may be of use in the obesity epidemic. In the following piece, we
will review the research linking addiction and eating, but most importantly, we will
identify directions for future research in this relatively new field of study.

FOUNDATIONAL RESEARCH
The food environment that we live in has changed dramatically over the past
several decades. Ultraprocessed, highly palatable food stuffs are cheap, easily accessible and heavily marketed. The addition of higher levels of sugar
has been one of the major drivers of this change, along with increased levels
of fat, salt, refined flours, and food additives. Hyperpalatable food, such as
ice cream, cookies, cakes and candy, exceed the level of reward associated
with more natural, minimally processed food, such as vegetables, fruits, and
nuts. The rising rates of obesity and recent recognition of BED (binge eating
disorder) as a distinct diagnosis that have accompanied the influx of these
types of food have led to the hypothesis that hyper-palatable food may be
capable of triggering an addictive process.
Foods and drugs of abuse both activate the neurotransmitter dopamine,
which has been implicated in reward processes. Further, increased food
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

palatability appears to be associated with a more marked activation of
the reward system (Volkow, Wang, Fowler, & Telang, 2008). Obesity and
substance dependence share certain neural underpinnings, such as increased
activation in motivation-related brain regions in response to cues and diminished activation in reward regions in response to consumption (Volkow
et al., 2002, 2008). BED also shares significant overlap with addiction. The
diagnostic criteria for BED and substance dependence include a number of
similar characteristics, such as diminished control over consumption and
continued use despite negative consequences (Volkow, Wang, Tomasi, &
Baler, 2013). Study participants with BED also appear to exhibit potential
dysfunction in neural regions implicated in executive control and reward
processing relative to healthy controls (Balodis et al., 2013; Wang et al., 2011;
Weygandt, Schaefer, Schienle, & Haynes, 2012), a pattern that has also been
noted in addictive disorders. These findings raise the possibility that similar
to addictive disorders, the diminished control over food consumption associated with BED may be related to neural differences in regions implicated
in executive control and reward processing. Thus, it has been suggested that
these parallels may reflect the role of an addictive-like process in obesity
and binge eating.
RECENT RESEARCH
ANIMAL MODEL RESEARCH
Intriguing animal model research suggests that certain food stuffs or ingredients may be capable of triggering an addictive process. Rats maintained on a
limited access schedule to a sugar solution exhibit several behaviors that are
commonly associated with substance dependence. For example, these animals tend to show larger and fewer eating episodes than controls, which is
thought to reflect “bingeing” (Avena, Rada, & Hoebel, 2008). Further, after
a period of abstinence, these animals show a marked increase in responding for sugar, which is considered an indication of craving (Avena, Long, &
Hoebel, 2005). When administered an opioid antagonist, which blocks opioid
receptors, or fasted from all food for 36 h, these animals also show evidence
of opiate-like withdrawal, including teeth chattering, forepaw tremors, and
head shakes (Avena, Bocarsly, Rada, Kim, & Hoebel, 2008; Colantuoni et al.,
2002). In addition, Oswald, Murdaugh, King, and Boggiano (2011) found that
rats prone to binge eating will endure greater magnitudes of electric shock
to obtain palatable food than those resistant to binge eating. Further, unlike
rats with no access or 1 h/day access to a cafeteria diet consisting of various meats, cakes, frosting, and chocolate, rats with extended access (18–23
h/day) to this diet do not decrease their intake of palatable food when shown

Emerging Evidence of Addiction in Problematic Eating Behavior

3

a stimulus associated with a foot shock (Johnson & Kenny, 2010). These two
findings provide evidence that such animals will pursue the reward associated with palatable food consumption despite adverse consequences. Recent
research has also shown that rats prefer a sucrose solution to both cocaine and
heroin when given the option to press a lever associated with each (Madsen
& Ahmed, 2014).
These behavioral indices of addiction are accompanied by neurochemical
alterations. For example, sugar consumption has been shown to repeatedly
increase dopamine within the nucleus accumbens, a brain region associated
with reward, of rats given intermittent sugar and chow access (Rada, Avena,
& Hoebel, 2005). In contrast, although rats given intermittent chow access
show an initial spike in dopamine, over time, this response decreases. However, rats with intermittent sugar and chow access continue to release high
levels of dopamine when given sugar, which reflects the pattern seen with
morphine administration (Pothos, Rada, Mark, & Hoebel, 1991). In addition,
Johnson and Kenny (2010) have found that rats with extended access to
the cafeteria diet mentioned above show a decrease in a type of dopamine
receptor (D2 receptors) within the striatum compared to control groups.
This is noteworthy as a number of studies have shown reduced striatal D2
receptors among individuals with substance dependence disorders (Fehr
et al., 2008). Further, rats that were genetically modified to have less striatal
D2 receptors demonstrate increased reward thresholds, suggesting that they
require greater stimulation to experience reward (Johnson & Kenny, 2010).
Findings such as these indicate underlying neurochemical abnormalities
that may result from and/or perpetuate addictive behaviors regarding
food.
HUMAN RESEARCH
Although there are strong parallels in brain regions that encode reward from
drugs and palatable food and in neural abnormalities associated with substance dependence and obesity/BED, these findings may tell us little about
true “food addiction.” Obesity is often linked to excess food consumption,
but other factors can contribute to unhealthy weight gain, including physical inactivity, medication side effects, and metabolic conditions. In addition,
excess consumption of a substance is not necessarily indicative of substance
dependence, or an “addiction.” For example, 40% of college students are
reported to binge drink (O’Malley & Johnston, 2002), but only 6% meet criteria for alcohol dependence (Knight et al., 2002). Further, addictive disorders
are typically diagnosed in the presence of certain behavioral indicators (e.g.,
loss of control, continued use despite negative consequences) (Table 1). Thus,

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Table 1
Diagnostic Criteria for Substance Dependence as Stated in the
DSM-IV-TR (APA, 2000)
1. Tolerance, as defined by either of the following:
a. The need for markedly increased amounts of the substance to achieve
intoxication or desired effect
b. Markedly diminished effect with continued use of the same amount of the
substance
2. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the substance
b. The same (or closely related) substance is taken to relieve or avoid withdrawal
symptoms
3. Taking the substance often in larger amounts or over a longer period than was
intended
4. There is a persistent desire or unsuccessful effort to cut down or control substance
use
5. Spending a great deal of time in activities necessary to obtain or use the substance or
to recover from its effects
6. Giving up social, occupational, or recreational activities because of substance use
7. Continuing the substance use with the knowledge that it is causing or exacerbating a
persistent or recurrent physical or psychological problem

when assessing food addiction, it would be useful to identify individuals
who exhibit similar signs of addiction with respect to their eating behavior
in addition to observing neural responses to food cues and receipt.
The Yale Food Addiction Scale (YFAS) was developed to operationalize
the construct of palatable food dependence (Gearhardt, Corbin, & Brownell,
2009) based on the DSM-IV-TR substance dependence criteria (APA, 2000).
A recent study found that the risk of YFAS “food addiction” increased with
obesity status and the severity of addictive-like eating was positively related
to measures of adiposity [e.g., body fat, BMI (body mass index)] (Pedram
et al., 2013). Further, addictive-like eating, as measured by the YFAS, has
been associated with a higher likelihood of a composite index of elevated
dopamine signaling (Davis et al., 2013), as well as a greater severity of
disordered eating (Gearhardt et al., 2012). In addition, when anticipating
food receipt, higher YFAS scores have been related to increased activation
of brain regions associated with craving and the motivation to eat, which
may resemble elevated motivation elicited by cues in addicted populations
(Gearhardt et al., 2011). Also akin to addictive disorders, this study found
an association between higher YFAS scores and reduced activation in
neural regions implicated in inhibitory control during palatable food receipt
(Gearhardt et al., 2011). Notably, the high and low “food addiction” groups
in this study did not differ by BMI and the results of the study remained

Emerging Evidence of Addiction in Problematic Eating Behavior

5

the same even after controlling for body weight. Therefore, behavioral
indicators of addictive-like eating are related to neural activation implicated
in addictive disorders even apart from the possible effects of elevated body
weight. This finding highlights the importance of viewing BMI and “food
addiction” as separate with overlap in certain cases.
Similarly, BED and YFAS “food addiction” are related to one another but
there also appear to be distinctions between the two. Approximately fifty
percent of obese patients diagnosed with BED meet the “food addiction”
threshold (Gearhardt, White, Masheb, & Grilo, 2013; Gearhardt et al., 2012),
which suggests that not all BED patients endorse addictive-like eating. In
BED patients, elevated YFAS scores are related to more frequent binge eating
episodes, elevated emotion dysregulation, and increased eating pathology
(Davis, 2013; Gearhardt et al., 2012, 2013). Thus, “food addiction” may be
associated with more severe pathology in the context of BED (Gearhardt et al.,
2012; Gearhardt, Roberto, Seamans, Corbin, & Brownell, 2013), perhaps making it more difficult to treat. This is consistent with prior research suggesting
that a BED diagnosis does not reflect a homogenous group, but rather that
there are subtypes within the diagnosis. One BED subtype is indicated by
high-levels of dietary restraint while another exhibits greater negative affect,
impulsivity, and overall pathology (Grilo, Masheb, & Wilson, 2001; Stice et al.,
2001). These two subtypes of BED could potentially be driven by different
mechanisms, with an addictive process possibly associated with the latter
subtype but not the former.
KEY ISSUES FOR FUTURE RESEARCH
Although there has been substantial progress in the study of addictive-like
eating, this is a relatively new area of research and there are still more questions than answers. One of the most important areas for future research is to
examine what types of food or components of food may be capable of triggering an addictive process. Especially in the human literature, the vast majority of research has focused on who may be experiencing an addictive-like
response to food, but less attention has been paid to identifying the possible
addictive ingredients of food. The identification of the addictive agent will
provide important information about the mechanisms driving compulsive
eating. It is clear that all food stuffs are not equal in their ability to trigger
addictive-like eating. For example, it is very rare for someone to report binging on broccoli or eating chicken breasts until they are uncomfortably full. In
contrast, food rich in added sugars, refined carbohydrates, and/or fats (e.g.,
candy, chocolate, French fries, cheese burgers, and pasta), are much more
likely to be described as problematic. At this point, sugar has been identified
as the most likely culprit in eliciting addictive behaviors based on findings

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

from animal models and some neuroimaging research (Avena, Rada, et al.,
2008; Stice, Burger, & Yokum, 2013). However, many of the food stuffs that
seem to induce cravings and loss of control contain ingredients other than
sugar (e.g., fat, other refined carbohydrates, salt), indicating a need for further research in this area. In addition, it may be beneficial to assess possible
interactions between ingredients.
A better understanding of which types of food or ingredients tend to result
in addictive behaviors may also inform policy and treatment approaches.
The greatest tobacco-related public health gains were made when policy
approaches altered the price and access to cigarettes, as well as other nicotine
products, and the companies creating and marketing these products became
more culpable. If certain food stuffs are identified as addictive, this may
be helpful in understanding the specific ways in which our environment
encourages excessive consumption of these food stuffs and identifying
effective targets for policy interventions. For example, food marketing is
a major source of cues for potentially addictive food stuffs in our environment and the industry spends millions of dollars to ensure that these
advertising campaigns are effective. Recent research has identified that food
commercials, relative to other types of commercials, are more effective in
triggering reward circuitry in the brains of adolescents (Gearhardt, Yokum,
Stice, Harris & Brownell, 2014). If certain food stuffs are found to be capable
of triggering an addictive response, this may inform policy debates about
restricting the advertising of these products, especially to children.
There are also a number of treatment implications of “food addiction” that
are yet to be explored. One commonly held approach in the treatment of
eating-related problems is that there are no “good” or “bad” types of food.
For individuals struggling with overeating highly palatable food, the implicit
message is that their struggles are a result of deficiencies in their willpower.
Although there are certainly individual differences that may increase the
risk of overeating, there are also likely properties of certain food stuffs that
differentially activate the reward system and may perpetuate compulsive
eating. One of the most controversial implications of the addiction construct
is that some individuals may benefit from the elimination of certain types
offood from their diet, similar to the elimination of alcohol for individuals
with alcohol use disorders. This raises concerns from other perspectives,
including the fear that this increase in dietary restraint may backfire and
trigger more disordered eating (Polivy, 1996). Although support for the
restraint hypothesis of disordered eating is mixed, this is a valid concern
and a research topic that needs to be examined empirically, particularly
among those who met the criteria for a “food addiction.” For example,
it may be insightful to examine the outcomes of existing programs that
employ an abstinence approach to kinds of certain food, such as Overeaters

Emerging Evidence of Addiction in Problematic Eating Behavior

7

Anonymous and Food Addicts Anonymous. Other aspects of addiction
treatment are consistent with traditional approaches to treating problematic
eating behaviors and many addiction-related strategies are already being
implemented in eating-focused interventions, such as identifying triggers,
coping with cravings, developing alternative ways to cope with negative
emotions, motivational interviewing and relapse prevention (Gearhardt,
White, & Potenza, 2011; von Ranson & Robinson, 2006).
To increase the effectiveness of these intervention approaches and to more
appropriately evaluate the “food addiction” hypothesis, it will be important
to identify phenotypes that reflect addictive-like eating rather than using
rough proxies. As mentioned previously, obesity has been frequently
used as a proxy for addictive eating and critics of the “food addiction”
hypothesis point out that the neurobiological parallels between obesity
and addiction are somewhat inconsistent (Ziauddeen, Farooqi, & Fletcher,
2012). Yet, obesity is a heterogeneous condition and it is highly unlikely
that all obesity results from “food addiction.” Further, not all individuals
with a healthy BMI have a normal relationship with food. Thus, the use
of weight status to indicate addictive-like eating likely results in both the
over- and under-identification of “food addicts,” which may contribute to
discrepancies in the literature (Avena, Gearhardt, Gold, Wang, & Potenza,
2012). Developing a better understanding of the subtypes of individuals
most prone to addictive-eating behavior will be essential to more precisely
examine whether addictive mechanisms are truly contributing to problematic eating and to match patients to the most appropriate treatment.
The YFAS is one tool that attempts to classify this subtype but further
evaluation is needed and additional tools, such as clinical interviews, may
be warranted.
Further, certain mechanisms implicated in addiction have received little
empirical evaluation regarding their role in problematic eating. Tolerance
and withdrawal are key indicators of physiological dependence to an addictive substance. Although neither of these criteria is required for a diagnosis of substance dependence, tolerance and withdrawal are often considered
key characteristics of addiction. Reviews critical of the validity of the food
addiction construct will state that there is no evidence of withdrawal or tolerance with such eating behaviors (Drewnowski & Bellisle, 2007; Wilson, 2010;
Ziauddeen et al., 2012), but this is premature given the marked lack of studies
in the area and the evidence for withdrawal and tolerance to sugar demonstrated in animal models. In one of the only studies on this topic in humans,
Spring et al. (2008) found that after repeated administrations, carbohydrate
cravers exhibited tolerance to the pleasant affective consequences of consuming a carbohydrate-rich shake (compared to a placebo shake). Regarding
withdrawal, there have been anecdotal reports of headaches, irritability, sleep

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

disturbance, chills and low mood among dieters cutting down on refined carbohydrates (Atkins, 2002). Empirical research is needed to explore whether
behavioral, biological, and psychological indicators of withdrawal and tolerance are present among humans who report problematic eating behavior,
and if certain types of food are more likely to trigger these responses than
others.
Finally, little is known about the role that addictive-like eating may play
in childhood obesity. In the substance dependence literature, an earlier age
of exposure to addictive substances (e.g., alcohol, nicotine) is implicated
in risk for the development of future problematic substance use (DeWit,
Adlaf, Offord, & Ogborne, 2000). This risk may result from adaptations in
a vulnerable neural system (Tapert, Caldwell, & Burke, 2005), as well as
an increased likelihood to use substances to cope psychologically (Clark,
Thatcher, & Tapert, 2008). If certain types of food also have addictive
potential, children may be especially susceptible to this effect as a result of
neural and psychological vulnerabilities.
There is some evidence to suggest that addictive processes may be at
play in problematic eating behavior in children. In a qualitative study of
overweight/obese 8–21 year olds, behaviors consistent with addiction (e.g.,
tolerance, cravings) were frequently described and 66% identified addiction
as a contributor to their eating problems (Pretlow, 2011). In addition, 15.2%
of children receiving treatment at a pediatric lipid clinic reported that they
often, usually, or always felt addicted to food and reports of addictive
eating were related to more significant eating problems (Merlo, Klingman,
Malasanos, & Silverstein, 2009). Recently, the YFAS was adapted to be
administered to children. Elevated scores on this measure were associated with greater BMI. Further, children with higher YFAS scores were
more likely to emotionally eat and to be less responsive to satiety signals
(Gearhardt et al., 2013). An important area of future research is to examine
whether neurobiological parallels to addiction are seen in children who
report addictive-like eating behaviors. In addition, animal models suggest
that addictive-like consumption of sugar increases the propensity to be
sensitized to other drugs of abuse (Avena, Carrillo, Needham, Leibowitz, &
Hoebel, 2004; Avena & Hoebel, 2003). Thus, it will be important to examine
whether addictive-like eating patterns early in development increase the
likelihood for future problems with drugs of abuse.
Accumulating evidence suggests that addictive processes marked by
behavioral changes and brain adaptations may develop in response to
palatable food and beverage consumption. Further research is needed,
however, to more fully understand the specific components of such food
and beverages that may contribute to addiction-like symptoms. In addition,

Emerging Evidence of Addiction in Problematic Eating Behavior

9

further study is needed to explore and characterize certain features of addiction, such as tolerance and withdrawal, among human samples. Finally, it is
critical to begin assessing the effects of palatable food consumption during
vulnerable periods of development, such as childhood and adolescence.
With progress in these areas, this emerging field of research may lend
practical insight into the public health and psychological issues of both
binge eating behavior and obesity.
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ASHLEY GEARHARDT SHORT BIOGRAPHY
Ashley Gearhardt, PhD, is an Assistant Professor of Clinical Psychology
at the University of Michigan. While working on her doctorate in clinical
psychology at Yale University, Dr. Gearhardt became interested in the
possibility that certain food stuffs may be capable of triggering an addictive
process. To explore this further, she developed the Yale Food Addiction
Scale (YFAS) to operationalize addictive-like eating behaviors. Scores on this
scale have recently been linked with more frequent binge eating episodes
in clinical populations, increased prevalence of obesity and patterns of
neural activation implicated in other addictive behaviors. Dr. Gearhardt
also investigates the impact of certain components of the food environment,
such as food advertising, on obesity risk through the use of multi-method
approaches (e.g., neuroimaging, eye tracking). She is currently the director
of the Food and Addiction Science and Treatment (FAST) lab to further
evaluate whether addictive-like mechanisms contribute to certain types of
problematic eating behavior. Web site: http://fastlab.psych.lsa.umich.edu/
SUSAN MURRAY SHORT BIOGRAPHY
Susan Murray is currently a research assistant in Dr. Nicole Avena’s laboratory at the Icahn School of Medicine, Mount Sinai. Susan received a BS in psychology from Fordham University in 2012. Her academic interests include
the study of eating disorders, obesity, and coping mechanisms. She has published five articles in scholarly journals and two book chapters on topics
related to the neural correlates of under- and overeating, obesity, and food
addiction.
NICOLE M. AVENA SHORT BIOGRAPHY
Dr. Nicole M. Avena is a research psychologist and neuroscientist with interests in the fields of nutrition, diet and addiction. She received a PhD in Psychology and Neuroscience from Princeton University in 2006, followed by a
postdoctoral fellowship at Rockefeller University. Dr. Avena presently holds

Emerging Evidence of Addiction in Problematic Eating Behavior

13

a faculty position in the Department of Pharmacology and Systems Therapeutics at the Icahn School of Medicine, Mount Sinai. She has published over
60 scholarly journal articles on topics related to diet, nutrition and overeating. Her research achievements have been honored by awards from groups
including the New York Academy of Sciences, the American Psychological
Association, and the National Institute on Drug Abuse.
Dr. Avena has a website www.DrNicoleAvena.com, a blog on Psychology
Today, and you can also follow her on Twitter or Facebook.

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