I am a principal and the Professional Training Coordinator at ACORN Food Dependency Recovery Service, a treatment and training program based in

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2 I am a principal and the Professional Training Coordinator at ACORN Food Dependency Recovery Service, a treatment and training program based in Sarasota, Florida. I have written and published several books, chapters and articles in the field of food addiction. I have no other relationships with commercial organizations of any kind to disclose.

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4 1. Introduction 2. Three levels of complexity in obesity a. Normal eaters with obesity b. Emotional eaters with eating disorders c. Food addicts with a chemical dependency 3. Stages of food addiction progression and recommended treatments for each 4. A vision of what physicians and other health professionals, with very limited time available to them, can do to treat food addiction 5. Some important questions we need to pursue together

5 50% of obese adults were food addicted 30% of the overweight adults were food addicted 20% of the "normal weight adults were food addicted ~ Dr. David Kessler, former commissioner of the Food and Drug Administration and Dean of Yale Medical School, in an NPR interview about his book, The End of Overeating. I estimate that there are about 70,000,000 in the United States that would identify as having food cravings, obsession about food much of the day. from Dr. Kessler s recent book for young adults, Your Food is Fooling You.

6 When a problem of being overweight or obese is only physical, there can be many external contributing factors: Sedentary jobs, Food in more variety, More sugar in all foods Increased TV and computer time More and more restaurants serving late Proliferation of gas station convenience stores filled with junk foods But control and use of will power are still possible. Needed: Medically approved diet Moderate exercise Support for eating, exercise and lifestyle change

7 When people start using food as a primary coping mechanism to deal with stress and difficult feelings, problems of being overweight or obese (and underweight or purging), they are considered emotional eaters. Emotional eaters often suffer from prior abuse - physical, emotional, sexual, and/or spiritual - and use food and eating behaviors to cope Often don t have the skills to deal with difficult feelings This turns out to lead to loss of control for this group. Needed: Counseling or mindfulness training is often recommended Sometimes extended therapy over years with an eating disorder or trauma specialist/program is required In some cases, intensive inpatient rehab may be necessary

8 When issues of chemical dependency on food develop with overweight, obese or eating disordered people, the problem can progress further and become almost completely intractable. The brain develops a stronger preference for foods that are calorie-rich and high in sugar, fat and salt Consuming a lot of these foods starts to activate the brain s reward system and triggers the release of the pleasure hormone dopamine, in the same way other addictive substances do so the brain begins to want more and more The rewarding nature of these foods can encourage eating to continue whether or not we are hungry, thus making it difficult to stop (this is physical craving) Needed: They need to discover and accept that they are food addicted (resolving denial) They need to completely eliminate specific foods that are toxic for them They require enough support to offset their loss of control They need to commit to a process of undoing the emotional and spiritual damage their addiction has caused them and others

9 NORMAL EATER (with obesity) EMOTIONAL EATER (eating disorder) FOOD ADDICT (chemical dependency) The problem is physical: Weight The solution is physical: Medically approved diet Moderate exercise Support for eating, exercise and lifestyle change What works: Willpower (less calories in, more calories out) The problem is physical and mentalemotional: Binge eating, restricting, and/or purging over feelings Unresolved trauma And possibly weight (sometimes overweight and sometimes underweight) The solution is mental-emotional and physical Develop skills to cope with feelings other than with restricting, purging and bingeing Resolve past emotional trauma and irrational thinking (heal trauma) Same as for Normal Eater What works: Moderate Eating (challenge irrational thinking, resolve prior trauma) The problem is physical, mentalemotional and spiritual: Physical craving (false starving) Mental obsession (false thinking) Self-will run riot (false self) And often trauma and weight The solution is physical mentalemotional and spiritual: Abstinence from binge foods and abusive eating behaviors Rigorous honesty about all thoughts and feelings A disciplined spiritual program, e.g. The Twelve Steps All those for Normal & Emotional Eaters What works: Surrender [complete commitment to battling a chronic condition] (no addictive foods, ask for help, work a spiritual program)

10 Weight Loss for Overweight and Obese Normal Eaters: less calories in, more calories out Yes, many overweight and obese normal eaters can lose weight and maintain a healthy weight by diet, exercise and life style change. If the needed weight loss is minimal, it might take one or two months. If it is hundreds of pounds it may take a few years. Two examples: 1. Most scientific studies show that diets don't work for most people but there are almost always some in each study who diet successfully. 2. Consumer Reports 7,000 reader study of the effectiveness of commercial weight loss programs. (10 to 30% of participants had a substantial weight loss and maintained it for at least a year 70 to 90% did not)

11 Weight Loss for Overweight and Obese Emotional Eaters: It's not the food you re eating; it's what's eating you. Emotional Eaters (emotional eating disorders) are treated by helping a client to analyze and reframe past abuse, develop cognitive behavioral therapy and/or mindfulness skills, and/or find appropriate medication. If there is an emotionally healthy parent or friend, their help may be enough Others need to work with one of the thousands of CBT or mindfulness trained eating disorders specialists Therapy may be brief or extend over years There are hundreds of good eating disorder treatment clinicians and programs in the United States The research seems to say that the particular form of therapy is not as important as the empathy and experience of the therapist. What we know for sure is that a large percentage of those treated for eating disorders do recover, and they become more like normal eaters.

12 Weight Loss for Food Addicts: (underweight or obese) Abstinence first, rigorous honesty & a spiritual program Food addicts also progressively lose their ability to control their eating and weight, but for a very different reason than those with eating disorders, and require special and different treatment. It is the chemical interaction of specific foods with the brain which causes food addiction. It is a true substance use disorder. The resulting physical craving operates unconsciously and begins to distort the conscious mind. Food addicts progressively believe things about their disease that are not true, including that they don t have the disease. Food addiction is treatable Through extraordinary support, abstinence from sugar and other specific foods, being rigorously honest about food and life, and by working a spiritual practice, e.g., the Twelve Steps Unlike in eating disorder treatment where the goal is to learn to eat all foods including sugar in moderation and become more like a normal eater, in food addiction, the goal is to accept that you are not a normal eater, and probably never will be, and learn how to manage your chronic condition.

13 1. A food plan that eliminates specific binge and trigger foods, provides a nutritious balance of foods, and supports slow, steady weight loss 2. Education about addiction as a disease of the brain 3. Participating in a community of support 4. Challenging of food addiction denial 5. Work on underlying emotional and spiritual problems.

14 Food Addiction: Progression and Recommended Actions Disease Stage Recommended Actions Pre-Disease No sign of abnormal eating or reactions to specific foods. If no dependency or pathology develops, this stage will continue through the person s entire life. Early Stage Problems with weight management, cycles of weight gain followed by dieting, weight loss, and weight gain again. (Occasional binge eating on sugar, excess fat, or volume could be early-stage food addiction or a normal eater making unhealthy choices.) Middle Stage Frequent binge eating and grazing. Purging or severe restriction may begin. Rationalizing before eating, guilt afterward. Could be advancing food addiction or emotional problem eater with a psychologically based eating disorder. Prevention Education about food addiction. Ongoing checks for signs of chemical dependency. Moderation in eating, especially commonly addictive foods, e.g., sugar, caffeine, excess fat, alcohol, drugs. Detox and Abstinence Identify addictive foods. Eliminate binge and trigger foods. Move through detoxification. This often seems extreme if negative consequences are not yet severe. This can be the beginning of addictive denial. Twelve Step Group/Counselor Participation in a food-related Twelve Step program, e.g., Overeaters Anonymous, and/or work with a food addictions counselor. Assistance with addressing blocks to physical abstinence, especially denial. Develop feeling skills, resolve trauma.

15 Late Stage Serious consequences from overeating morbid obesity, Type II diabetes, chronic depression and/or spiritual disillusionment, and eating anyway. Food no longer provides comfort, escape, oblivion, etc. Loss of control, increasing tolerance Final Stage More Structure and Support Participation in a highly structured Twelve Step program, e.g., Food Addicts in Recovery Anonymous, Compulsive Eaters Anonymous HOW. Outpatient treatment and/or workshops such as those offered by ACORN. Abstinence as a spiritual path. Primary Inpatient or Residential Treatment Severe consequences hospitalization for heart attacks, suicide attempts, lost jobs or inability to work, ruined relationships, treatment and/or intestinal surgery followed by relapse, housebound or confined to nursing homes. Given the lack of any hospital-based inpatient treatment for food addiction, alternatives include Turning Point of Tampa, Milestones in Recovery, Shades of Hope, ACORN s year-long Living in Abstinence program. This is sometimes insufficient. DEATH

16 1. Getting the Food Right 2. Learning about Addiction and Brain Disease 3. Becoming Rigorously Honest 4. Challenging Food Addiction Denial 5. Doing the Deeper Emotional and Spiritual Healing

17 In an ideal world, it would be helpful if all physicians, dieticians, therapists and allied health professionals do the following: 1. Tell their clients that the science is now conclusive: specific foods can be addictive just like alcohol and drugs 2. Screen regularly for use of sugar and layered addictive foods, e.g., administer the S-Uncope or ask a question about loss of control 3. For those screening positive, request an assessment, e.g. the Yale Food Addiction Scale (YFAS) 4. For those with substantial food addiction, refer for a diagnosis and treatment plan, e.g. a sugar/food version of the Swedish ADDIS 5. Make available a list of local and phone food-related Twelve Step meetings and a volunteer "ambassador" to offer guidance 6. For those unable to eliminate toxic foods, offer referrals to food addiction professionals and/or treatment 7. Support the development of a ladder of professional services for food addicts in the local community and full recognition of food as a substance use disorder in the DSM-5.

18 1. How do we reach all physicians, dietitians and therapists with the new information on the science, diagnosis and treatment of food addiction? 2. How do we cooperate with food-related Twelve Step fellowships, religion based support and other free services? 3. How do we develop a ladder of professional services for food addicts - screening, diagnosis, counseling and treatment - in every community? 4. How do we re-establish primary, hospital based research and treatment for food addiction in every state and major metropolitan area? 5. How do we create food addiction prevention programs, especially for parents and children, in the schools, public media and elsewhere? 6. How can all local institutions in a community - grocery stores, restaurants, schools, churches, weight loss organizations and gyms, businesses, hospitals, police and military, prisons contribute to prevention of and recovery from food addiction? 7. How do we create local, state and national laws regarding sugar, layered and other potentially addictive foods comparable to those for alcohol and drugs? 8. How do we encourage epidemiological research on food addiction prevalence and treatment outcomes?

19 PO Box Sarasota, FL PO Box Sarasota, FL