July 18, 2024


Great Health is a Choice

Food Addiction Should Be Included in the DSM-6

Food Addiction Should Be Included in the DSM-6

Dennis is a psychiatrist and certified eating disorder specialist. Brewerton is an affiliate professor of psychiatry and behavioral sciences.

In the evolving landscape of mental health diagnostics, the Diagnostic and Statistical Manual of Mental Disorders (DSM) stands as the cornerstone. While it is far from a perfect tool, its revisions shape clinical practice and legitimize acceptance of mental health conditions that affect large numbers of patients. Without an accurate diagnosis, patients will continue to experience undue stigma, misdiagnosis, and poor prognosis.

With DSM-6’s anticipated release in the next few years, there is an urgent need to legitimize food addiction — also known as ultra-processed food addiction (UPFA), or the preferred term for DSM-6, ultra-processed food use disorder (UPFUD) — under the current substance- and addiction-related disorders category.

Models of Addiction

The concept of food addiction aligns with the neurobiological model of addiction, which illustrates that addictive substances hijack the brain’s reward system, leading to compulsive use and loss of control. Research using neuroimaging techniques has revealed neural responses to highly palatable foods similar to responses to addictive substances like cocaine and heroin.

Moreover, individuals with food addiction often exhibit behavioral patterns consistent with addiction, such as tolerance (needing more of the substance to achieve the same reward), withdrawal symptoms (negative emotions or physical symptoms when cutting back), and continued use despite negative consequences (such as disordered eating, depression, or obesity-related health issues). These parallels underscore the urgent need to recognize food addiction as a legitimate psychiatric disorder deserving of research, public policy changes, clinical attention, and treatment.

Countering the Naysayers

Some oppose the idea of adding food addiction to the DSM. Critics of formalizing food addiction in the DSM argue that eating is a necessary and natural behavior, unlike ingesting substances like alcohol or drugs, which involves the consumption of external chemicals. This argument overlooks the fact that certain foods, particularly those high in sugar, fat, and salt, can trigger addictive responses in susceptible individuals, and involves the consumption of external chemicals or highly processed food additives. The pervasive availability of these hyperpalatable foods in our current food environment exacerbates the problem.

Other critics claim that the clinical phenotype is already captured by other diagnoses, namely binge eating disorder (BED) or clinical obesity. This is a controversial clinical issue, particularly among eating disorder professionals, where the concept of UPFA is conflated with diet culture and pathological dietary restraint (which are prominent symptoms in anorexia nervosa and atypical anorexia nervosa). We believe UPFA is highly comorbid with, yet clinically distinguishable from, bulimia nervosa (BN), BED, and clinical obesity. Further, there are patients with UPFA who do not have comorbid eating disorders or clinical obesity.

In DSM-5, published in 2013, the chapter on substance-related and addictive disorders fails to acknowledge the clinical phenotype associated with problematic use of hyperpalatable food. The evidence base that has exploded over the last 10 years convincingly (we would argue definitively) identifies UPFA as a legitimate clinical condition, overlapping with but distinct from BN, BED, and clinical obesity.

The Lack of a Formal Diagnosis Harms Patients

As clinician researchers, we face patients daily whose clinical presentations do not quite fit into the current DSM or International Classification of Diseases (ICD).

These patients are poorly served, and some even harmed, by approaches that fail to account for a comorbid food addiction diagnosis. For example, nearly all patients receiving eating disorder specialty care for BED, which studies show to be highly comorbid with food addiction, are treated with the “all foods in moderation” approach. This also includes patients who are misdiagnosed as having BED alone when they actually have BED plus comorbid UPFA.

In eating disorder treatment settings, these patients are uniformly encouraged to consume three meals and three snacks a day at regular intervals, without attempting to reduce or avoid any specific food types. This approach could be expected to poorly serve patients with comorbid food addiction, due to the brain reward activation and worsening of cravings and/or loss of control eating resulting from ingestion of certain foods.

However, taking a nutritional approach that explicitly supports the patient with BED and comorbid UPFA in reducing or abstaining from ultra-processed foods that are problematic for them might decrease cravings and improve their ability to eat when they are hungry, and stop eating when full.

New treatment approaches must be developed to help patients with comorbid conditions who are poorly served in standard medical practices (weight management clinics, with limited eating disorder screening and weight-focused care) and eating disorder clinics (with no food addiction screening, “all foods fit for everybody,” and limited integration of care for metabolic syndrome). Among treatment-seeking patients with BN and BED, only 30-50% achieve abstinence from binge eating episodes by end of treatment with current approaches. Our patients deserve much better.

Toward a New Paradigm

The omission of food addiction as a diagnosis not only worsens patient outcomes, but further perpetuates the problematic mindset in medicine that food-related issues are solely a matter of willpower or self-control, and the misconception in psychiatry that patients who fail to respond to standard eating disorder approaches are “not ready to let go of diet culture and the eating disorder.”

Food addiction in patients “failing” current treatments results from a complex interplay of biological, psycho-social, spiritual, and environmental factors. Understanding this can benefit the disease course across multiple diagnoses, both medical and psychiatric. If UPFA were to be made a legitimized diagnosis, researchers stand a chance of securing much-needed dollars to develop and test novel treatment approaches that improve outcomes for patients with food addiction alone, and for those with comorbidity who are poorly served with current eating disorder or clinical obesity interventions.

Adding food addiction to the menu in DSM-6 would have profound implications for public health policy. By formally acknowledging the addictive properties of certain foods, policymakers can implement measures to regulate their availability, marketing, and accessibility, and examine marketing practices targeting historically minoritized and economically disadvantaged populations — similar to strategies employed for tobacco.

Finally, healthcare providers can receive training in screening for food addiction, using the Yale Food Addiction Scale (YFAS, current version mYFAS 2.0), as well as screening for co-occurring eating disorders (many screens are publicly available, most used in primary care being the SCOFF questionnaire, or the Binge Eating Scale, BES, to screen for BED). Several treatment approaches are currently being studied in clinical populations who meet the criteria for food addiction, including treatment as usual for comorbid eating disorder or weight management, harm reduction approaches, and abstinence-based approaches.

Without a legitimate diagnosis, it will continue to be nearly impossible to ensure that affected individuals receive appropriate care, tailored to their unique needs.

Kim Dennis, MD, is a psychiatrist and certified eating disorder specialist. She is the Chief Medical Officer of SunCloud Health, a treatment center for eating disorders, addiction, and other mental health issues. She is a clinical assistant professor in the Department of Psychiatry at the University of Illinois Chicago College of Medicine.

Timothy D. Brewerton, MD, is an affiliate professor of Psychiatry & Behavioral Sciences at the Medical University of South Carolina in Charleston.