Food Addiction and Bulimia Nervosa

In individuals with obesity and binge eating disorder (BED), eating patterns can show addictive qualities, with similarities to substance use disorders on behavioural and neurobiological levels. Bulimia nervosa (BN) has received less attention in this regard, despite their regular binge eating symptoms. The Yale Food Addiction Scale (YFAS) was developed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria for substance use disorders, and food addiction can be diagnosed when at least three addiction symptoms are endorsed and a clinically significant impairment or distress is present. Although the prevalence of food addiction diagnoses is increased in individuals with obesity and BED, recent studies which used the YFAS showed that there are also individuals with normal weight who can be classified as being ‘food addicted’. Based on self‐reported eating disorder symptoms, women with current (n = 26) or remitted (n = 20) BN, and a control group of women matched for age and body mass index (n = 63) completed the YFAS and other measures. Results revealed that all patients with current BN received a food addiction diagnosis according to the YFAS while only six (30%) women with remitted BN did. None of the women in the control group received a food addiction diagnosis. Results provide support for the notion that BN can be described as addiction‐like eating behaviour and suggest that food addiction most likely improves when BN symptoms remit. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.     

Food Addiction in Overweight and Obese Adolescents Seeking Weight‐loss Treatment

Some forms of overeating closely resemble addictive behaviour. The Yale Food Addiction Scale (YFAS) was developed to measure such addiction‐like eating in humans and has been employed in numerous studies for examining food addiction in adults. Yet, little is known about food addiction in children and adolescents. Fifty adolescents were recruited at the beginning of treatment in a weight‐loss hospital and completed the YFAS among other questionnaires. Nineteen participants (38%) received a YFAS diagnosis, who did not differ in age, body mass and gender distribution from those not receiving a diagnosis. However, those with food addiction reported more binge days, more frequent food cravings, higher eating, weight and shape concerns, more symptoms of depression and higher attentional and motor impulsivity. Eating restraint and nonplanning impulsivity did not differ between groups. Results replicate findings from studies in obese adults such that food addiction is not related to age, gender, body mass or eating restraint, but to higher eating pathology, more symptoms of depression and higher impulsivity. Furthermore, results highlight that particularly attentional impulsivity is related to ‘food addiction’. Addiction‐like eating appears to be a valid phenotype in a substantial subset of treatment‐seeking, obese adolescents. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.     

Food Addiction in a Spanish Sample of Eating Disorders: DSM‐5 Diagnostic Subtype Differentiation and Validation Data

Although the concept of ‘food addiction’ (FA) has raised growing interest because of evidence for similarities between substance dependence and excessive food intake, there is a lack of studies that explore this construct among the wide spectrum of eating disorders (EDs). Besides providing validation scores of a Spanish version of the Yale FA Scale (YFAS‐S), this study examined the prevalence of ‘FA’ among ED subtypes compared with healthy‐eating controls (HCs) and the association between ‘FA’ scores, eating symptomatology and general psychopathology. A sample of 125 adult women with ED, diagnosed according to Diagnostic and Statistical Manual of Mental Disorders 5 criteria, and 82 healthy‐eating women participated in the study. All participants were assessed with the YFAS‐S, the ED Inventory‐2 and the Symptom Checklist‐Revised. Results showed that the internal structure of the one‐dimensional solution for the YFAS‐S was very good (α = 0.95). The YFAS‐S has a good discriminative capacity to differentiate between ED and controls (specificity = 97.6% and sensitivity (Se) = 72.8%; area under receiver operating characteristic curve = 0.90) and a good Se to screen for specific ED subtypes. YFAS‐S scores were associated with higher levels of negative affect and depression, higher general psychopathology, more severe eating pathology and greater body mass index. When comparing the prevalence of ‘FA’ between ED subtypes, the lowest prevalence of ‘FA’, measured with the YFAS‐S, was for the anorexia nervosa (AN) restrictive subtype with 50%, and the highest was for the AN binge–purging subtype (85.7%), followed by bulimia nervosa (81.5%) and binge eating disorder (76.9%). In conclusion, higher YFAS‐S scores are associated with bingeing ED‐subtype patients and with more eating severity and psychopathology. Although the ‘FA’ construct is able to differentiate between ED and HC, it needs to be further explored. Copyright © 2014 John Wiley & Sons, Ltd and Eating Disorders Association.     

Development of the Modified Yale Food Addiction Scale Version 2.0

The Yale Food Addiction Scale (YFAS) operationalizes indicators of addictive‐like eating, originally based on the Diagnostic and Statistical Manual of Mental Disorders 4th edition Text Revision (DSM‐IV‐TR) criteria for substance‐use disorders. The YFAS has multiple adaptations, including a briefer scale (mYFAS). Recently, the YFAS 2.0 was developed to reflect changes to diagnostic criteria in the DSM‐5. The current study developed a briefer version of the YFAS 2.0 (mYFAS 2.0) using the participant sample from the YFAS 2.0 validation paper (n = 536). Then, in an independent sample recruited from Mechanical Turk, 213 participants completed the mYFAS 2.0, YFAS 2.0, and measures of eating‐related constructs in order to evaluate the psychometric properties of the mYFAS 2.0, relative to the YFAS 2.0. The mYFAS 2.0 and YFAS 2.0 performed similarly on indexes of reliability, convergent validity with related constructs (e.g. weight cycling), discriminant validity with distinct measures (e.g. dietary restraint) and incremental validity evidenced by associations with frequency of binge eating beyond a measure of disinhibited eating. The mYFAS 2.0 may be an appropriate choice for studies prioritizing specificity when assessing for addictive‐like eating or when a briefer measurement of food addiction is needed. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.     

Factor Structure and Item Analysis of the Yale Food Addiction Scale in Obese Candidates for Bariatric Surgery

Converging research suggests phenomenological and neurobiological similarities between excessive food consumption and addictive behaviour in substance dependence. Recently, the Yale Food Addiction Scale (YFAS) has been proposed for the assessment of addictive eating behaviour. The German version of the YFAS was administered to obese individuals seeking bariatric surgery (N = 96). Factor structure, internal consistency, and item statistics were analysed. Forty participants (41.70%) received a food addiction diagnosis. The one‐factorial structure of the YFAS, which has been found in non‐clinical samples, could be confirmed. All but three items had factor loadings >.50. Internal consistency was α = .82. Item analysis revealed that items related to unsuccessful attempts to cut down and consumption despite physical and emotional problems were endorsed by the majority of participants. Findings support the use of the YFAS in clinical populations, while applicability of some items differs between clinical and non‐clinical samples. Copyright © 2012 John Wiley & Sons, Ltd and Eating Disorders Association.     

Associations of Food Addiction in a Sample Recruited to Be Nationally Representative of the United States

The current study investigated the prevalence of food addiction and its associations with obesity and demographic factors in a sample recruited to be more nationally representative of the United States than previous research. Individuals (n = 1050) were recruited through Qualtrics' qBus, which sets demographic quotas developed using the United States census reference population. Participants (n = 986) self‐reported food addiction, measured by the modified Yale Food Addiction Scale 2.0, height, weight, age, gender, race and income. Food addiction was observed in 15% of participants, with greater prevalence in individuals who were younger, Hispanic and/or reported higher annual income. Food addiction prevalence was higher in persons who were underweight or obese, relative to normal weight or overweight. Food addiction was associated with higher body mass index in women and persons who were older, White and/or reported lower income. Identifying the scope of food addiction and individual risk groups may inform public policy initiatives and early intervention efforts. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.     

Binge eating disorder and non‐purging bulimia: more similar than different?

There is evidence of an overlap of symptoms between binge‐eating disordered (BED) and bulimia nervosa non‐purging (BN‐NP) patients. In addition, there are indications of an evolution from bulimia nervosa to BED along a continuum of vulnerability. However, DSM‐IV categorizes BED and BN‐NP as distinct disorders based on clinical characteristics. In this study weight history and personality‐related characteristics (TCI; Cloninger, Svrakic, & Przybeck, 1993) were studied in 30 BED and 17 BN‐NP patients. BED patients were older, and had a longer duration of illness, a larger weight cycling, a higher current and previous BMI and a lower score for the temperament dimension ‘Persistence’ than BN‐NP patients. After correcting for age, differences between weight variables remained, including comparatively higher BMIs and larger weight fluctuations among the BED patients. A possible explanation is that this difference is due to a genetic effect of the propensity to be overweight and the temperamental characteristic of Persistence. This ‘morbid’ starting position and the lack of controlling mechanisms are associated with a more trait‐ than state‐dependent condition. Thus, restrained eating is not to be regarded as eliciting bingeing in BED patients. Due to personality characteristics these patients are not able to restrain, which clearly differentiates them from BN‐NP patients. Copyright © 2004 John Wiley & Sons, Ltd and Eating Disorders Association.     

Processing of five types of ‘threat’ information in anorexic and bulimic women

This study investigated further the ‘escape’ hypothesis of bulimia and compared the processing of ‘threat’ information in control, anorexic and bulimic women. Using a novel information‐processing task, five types of non‐eating ‘threat’ (autonomy, sociotropy, discomfort anxiety, ego threat from others and ego threat from self) were addressed. The women did not differ in response time taken to identify ‘threat’ information, although there was support for the ‘escape’ hypothesis of bulimia. Specific non‐eating ‘threat’ information appeared relevant to both anorexia and bulimia nervosa, suggesting the potential value of addressing general threat schemata in clinical practice. Copyright © 2004 John Wiley & Sons, Ltd and Eating Disorders Association.     

Effectiveness of day hospital treatment for anorexia nervosa and bulimia nervosa

The aim of this observational study was to examine the short‐term effectiveness of a structured, largely manualised day hospital treatment, as well as the stability of short‐term effects in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Eighty‐three patients, 47 with AN and 36 with BN, were assessed at pre‐treatment, at the end of the day hospital treatment and at follow‐up approximately one year after post‐treatment. Outcome measures were body mass index (BMI), disturbed eating attitudes and behaviours assessed by the Eating Disorder Inventory (EDI), frequency of bingeing and purging, and general psychopathology assessed by the Symptom Checklist‐90 (SCL‐90). At the end of the day hospital treatment, significant improvements could be found on all outcome variables (frequency of binge eating/vomiting/laxative abuse, BMI and core EDI‐subscales ‘drive for thinness’/‘bulimia’/‘body dissatisfaction’). Effect sizes were generally large (.74 > d < 2.44). The effects were maintained or improved until follow‐up (18 months). At follow‐up, 40.2% of AN patients and 40.4% of BN patients could be classified as remitted. General psychopathological impairment was also significantly reduced at post‐treatment and maintained until follow‐up. The results demonstrate both the short‐term effectiveness and long‐term stability of day hospital treatment in a large sample of patients with anorexia and BN. Copyright © 2008 John Wiley & Sons, Ltd and Eating Disorders Association.     

To Go or Not to Go: A Proof of Concept Study Testing Food‐Specific Inhibition Training for Women with Eating and Weight Disorders

Inefficient food‐specific inhibitory control is a potential mechanism that underlies binge eating in bulimia nervosa and binge eating disorder. Go/no‐go training tools have been developed to increase inhibitory control over eating impulses. Using a within‐subjects design, this study examined whether one session of food‐specific go/no‐go training, versus general inhibitory control training, modifies eating behaviour. The primary outcome measure was food consumption on a taste test following each training session. Women with bulimia nervosa and binge eating disorder had small non‐significant reductions in high‐calorie food consumption on the taste test following the food‐specific compared with the general training. There were no effects on eating disorder symptomatic behaviour (i.e. binge eating/purging) in the 24 h post‐training. The training task was found to be acceptable by the clinical groups. More research is needed with larger sample sizes to determine the effectiveness of this training approach for clinical populations. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.     

Differences among women who exercise for ‘food related’ and ‘non-food related’ reasons

Young female subjects who engage in exercise to ‘work off’ food they have consumed (‘food related’ exercisers) were compared with other young female subjects who engage in exercise with other objectives (‘non-food related’ exercisers). Assessment of subjects' attitudes and behaviours indicated that the ‘food related’ exercisers exhibited more symptoms of obligatory exercise, eating disturbance, body dissatisfaction, and lower self-esteem, than did the ‘non-food related’ exercisers. A subset of women in the ‘food related’ group who reported exercising for the primary reason of working off food, losing weight, or changing their appearance (the ‘food related/body dissatisfied’ exercisers), indicated even greater disturbance on these measures. The role of exercise in relation to eating disorders is discussed. Copyright © 1998 John Wiley & Sons, Ltd and Eating Disorders Association.     

The Processing of Food Stimuli in Abnormal Eating: A Systematic Review of Electrophysiology

To update the knowledge about attentional processing of food stimuli, a systematic review of electrophysiological studies was conducted using PubMed, PsychInfo and Web of Knowledge (2000–2014). Twenty‐one studies were included into a qualitative synthesis. Presentation of food and control pictures was used to analyze event‐related potentials related to sensory processing and motivated attention. Results show consistent attentional bias towards food pictures compared with neutral pictures for patient and control groups. Group comparisons between individuals with abnormal‐eating and healthy‐eating participants were more inconsistent. Results suggest that temporal differences in the millisecond range are essential for the understanding of visual food processing. In obesity, early attention engagement to food is followed by relatice disengagement. Loss of control eating, as well as external and emotional eating, are associated with a sustained maintenance of attention towards high‐caloric food. There is a lack of studies in anorexia nervosa, bulimia nervosa and binge eating disorder. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.     

The prevalence and psychological correlates of anorexia nervosa,bulimia nervosa and binge eating among 15‐year‐old students: a controlled epidemiological study

The present study reports on the prevalence of adolescent anorexia nervosa, bulimia nervosa and binge eating disorders. Also, the hypothesis by Slade (1982) suggesting ‘perfectionism’ and ‘general dissatisfaction’ as setting conditions for eating disorders was tested. A total of 678 15‐year‐old adolescents were screened, and those who scored above 10 on the ‘drive for thinness’ subscale on the Eating Disorder Inventory (EDI) were interviewed for suspected eating disorders. A gender‐ and age‐matched control group of low scores were also clinically interviewed. The interviewers were blind to whether individuals were suspected of having eating disorders or not. The Setting Conditions for Anorexia Nervosa Scale (SCANS) was used to test the setting condition hypothesis. Other variables included were the EDI subscales ‘Bulimia’ and ‘Body dissatisfaction’. Weight was calculated using the Body Mass Index. For the total material, we found 1.0 per cent with a binge eating disorder, 0.7 per cent with bulimia nervosa, 0.3 per cent with a bulimic subtype of anorexia nervosa and 0.7 per cent with subclinical bulimia nervosa. All subjects were girls. In addition, 3.5 per cent were considered ‘at risk’, of whom we identified 22 girls (3.2 per cent) and two boys (0.3 per cent). High scores on ‘perfectionism’ were unrelated to the presence of eating disorders. Controlling for ‘body dissatisfaction’, ‘general dissatisfaction’, on the other hand, was related to eating disorders and an ‘at‐risk’ condition. The prevalence figures in this age cohort equal those for older age groups. The weak support to the setting condition hypothesis may point to an inadequate instrument and not necessarily to a theoretically blind alley. Copyright © 1999 John Wiley & Sons, Ltd and Eating Disorders Association.     

Emotional responses to food in adults with an eating disorder: a qualitative exploration

There is a dearth of qualitative research exploring eating disordered individuals' emotional responses to the sight of different types of food. In this study we asked 10 adult women diagnosed with bulimia nervosa, anorexia nervosa or an eating disorder not otherwise specified (EDNOS) to articulate their thoughts whilst viewing slides of a range of different foodstuffs, during an in‐depth interview session. The data were transcribed and subjected to qualitative analysis. A core theme of ‘Control’ was identified. Whilst control has been previously acknowledged in the literature as an important aspect of eating disordered behaviour, this is the first report to link control with negative emotional responses to the sight of food. Clinically, an exploration of the notion of control and how it relates to particular foods may be beneficial in therapy. Copyright © 2007 John Wiley & Sons, Ltd and Eating Disorders Association.     

Oral control and body dissatisfaction in older adults: a note of caution

Responses of 99 older adults (mean age 75.5 years) on the EAT‐26 oral control subscale and the body dissatisfaction subscale of the Eating Disorders Inventory were examined in 29 congestive heart failure (CHF) patients who had lost a mean 8.5 kg in the preceding 12 months and in 21 CHF patients of stable weight and two groups of healthy older adults with no known weight loss. Whilst significant group differences on oral control were found (p<0.001) item analysis showed that 3/7 items correlated negatively with the subscale total. Endorsement of ‘oral control’ items did not necessarily denote an ‘eating disordered attitude’. Similarly item analysis of ‘body dissatisfaction’ totals showed a dissociation between general body dissatisfaction and ‘feeling too fat’. Caution is needed in interpreting eating attitude scales with older adults, however ‘eating disorders’ research should widen its focus to investigate groups other than the young women on whom most scales were standardized. Copyright © 2000 John Wiley & Sons, Ltd and Eating Disorders Association.     

Eating disorders,obesity and addiction

An addiction model of both eating disorders and obesity has received increasing attention in the popular and scientific literature. The addiction is viewed as a brain disease that must be directly targeted if treatment is to succeed. Evidence from laboratory feeding studies, epidemiology, genetic and familial research, psychopathological mechanisms, and treatment outcome research on cognitive behaviour therapy (CBT) is inconsistent with the clinical validity or utility of the addiction model of eating disorders. Neurobiological research has shown commonalities in brain reward processes between obesity and substance abuse disorders. Yet emphasis on apparent similarities overlooks important differences between obesity and drug addiction. Interest in obesity as a brain disease should not detract from a public health focus on the ‘toxic food environment’ that is arguably responsible for the obesity epidemic and related nutrition‐based chronic disease. Copyright © 2010 John Wiley & Sons, Ltd and Eating Disorders Association.     

Sensation seeking: a personality trait characteristic of adolescent girls and young women with eating disorders?

The aim of the following study was to evaluate the role of sensation seeking in eating disorders (anorexia and bulimia), taking into account the subtypes (purging versus nonpurging) and the concept of binge‐eating disorder. The study involved 141 adolescent girls and young women, aged 14 to 25 years who lived in the French speaking part of Switzerland (79 clinical subjects with eating disorders according to DSM‐IV criteria, and 62 control subjects without eating disorders from the general population). All the subjects completed the Sensation Seeking Scale (SSS, Zuckerman, 1971). The results show that subjects with bulimic behaviours characterized by recurrent episodes of binge‐eating, whatever their exact diagnosis and subtype, do not significantly differ from one another on the Sensation Seeking Scale. They all had higher scores than the control group especially on the ‘Thrill and Adventure Seeking’ dimension. In contrast, restricting anorexics had lower scores on the Sensation Seeking Scale than the control group, especially on the ‘Experience Seeking’ dimension. Copyright © 2000 John Wiley & Sons, Ltd and Eating Disorders Association.     

Dyscontrol evoked by erotic and food images in women with bulimia nervosa

The present study examined the emotional reactivity to erotic and food images of women with and without bulimia nervosa using the picture‐viewing paradigm. A non‐clinical student sample made up of 48 women, 24 diagnosed with bulimia nervosa and 24 healthy controls, aged between 18 and 27 years (M=21.79), participated in the study. Diagnosis was based on questionnaires and a structured interview following DSM‐IV criteria. Participants assessed a set of food, erotic, neutral and unpleasant pictures using the Self‐Assessment Manikin scales of valence, arousal and control. The women with bulimia nervosa rated as less pleasant the erotic and food pictures, which evoked greater dyscontrol, in comparison with the women without bulimia nervosa. No significant differences were found in the ratings for the remaining pictures. These results suggest that women with bulimia nervosa experience reduced pleasure and control over both food and sexual impulses. Copyright © 2006 John Wiley & Sons, Ltd and Eating Disorders Association.     

Motivators for smoking in women with eating disorders

Women with eating disorders sometimes smoke to control their weight. This study examined the relative contributions of the range of factors that motivate smoking in women with eating disorders. Twenty‐five women with anorexia nervosa and 16 women with bulimia nervosa were compared with 21 women with a depressive mood disorder. Each completed measures of current and lifetime prevalence of smoking, motivation to smoke and dependence on smoking. Smoking was less prevalent in anorexia nervosa than in bulimia nervosa or in mood disorders. Although the eating‐disordered women had a higher motivation to smoke for weight control than the mood‐disordered group, overall motivation to smoke was higher in the eating‐disordered women. Their strongest motivator for smoking was coping with stress. The eating‐disordered women showed similar levels of dependence on smoking to the mood‐disordered group, but tended to have a lower desire to give up smoking. Clinical interventions for women with eating disorders who smoke might be targeted at helping them cope with stress, as well as viewing their smoking as a method of weight control. Assessment of women with eating disorders should address the use of nicotine and motivations for its use, to help identify targets for intervention. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association.     

Reduced bone mineral density in bulimia as well as anorexia nervosa

We conducted a case controlled study to examine bone mineral density (BMD) in 47 women with bulimia nervosa, 51 with anorexia nervosa, 45 women recovered from past eating disorders, and 40 healthy controls. Lumbar spine and whole body BMD were measured by dual energy X‐ray absorptiometry. In contrast with previous studies, we found that subjects with active bulimia nervosa, even with no previous history of anorexia, had lower whole body and lumbar spine BMD than controls, although higher than in anorexia. Non‐traumatic spinal fractures were detected in two anorexic subjects and two bulimic subjects, but none of the controls. Assessment of BMD should be considered in patients with severe bulimia as well as anorexia nervosa. Copyright © 2004 John Wiley & Sons, Ltd and Eating Disorders Association.