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Food Res. Download references. We acknowledge C. Sanmiguel for her contributions in making editorial suggestions to the gut-directed therapies section of this review and C. Liu for invaluable editorial services. has been supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases DK, DK and DK Oppenheimer Family Center for Neurobiology of Stress and Resilience, Ingestive Behavior and Obesity Program, University of California Los Angeles, Los Angeles, CA, USA.
David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA. Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA, USA.
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The extensive network of neurons in the extended reward network that depend on dopamine as the primary neurotransmitter for reward-related processing. Processes associated with reward sensitivity, motivation, interoceptive awareness, stress reactivity and self-control.
Region of the basal ganglia and a key hub for the core reward system, responsible for many dopaminergic processes, especially those related to pleasure, motivation and aversion.
Key region of the midbrain that houses the dopaminergic cell bodies that project to all regions of the core and extended reward network.
The brain network responsible for monitoring the homeostatic state of the body to make adaptive adjustments to real or expected disturbances in homeostasis through the autonomic nervous system and behavioural responses. The extensive communication network between the cortex, which houses the extended reward network including the frontal cortex and insula and the striatum, which houses the core reward network nucleus accumbens, basal ganglia.
Dietary fibre or other substrates that can only be digested by commensal gut microorganisms, thereby promoting gut microbiota diversity and health. Behaviours used to cope with stressful situations to alleviate the stress or symptoms, but are not necessarily healthy and do not address the core cause of the stress.
Stress originating from the environment that is sufficient to cause dysregulation of homeostatic responses and physical or psychological symptoms. The most widely used scale for perceived stress is the Perceived Stress Scale.
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Skip to main content Thank you for visiting nature. Subjects Gastrointestinal models Obesity. Abstract Normal eating behaviour is coordinated by the tightly regulated balance between intestinal and extra-intestinal homeostatic and hedonic mechanisms. Key points Food addiction refers to maladaptive ingestive behaviours resulting from a shift from primarily homeostatic to hedonic regulatory mechanisms of food intake; this shift reflects alterations at all levels of the brain—gut—microbiome BGM axis.
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Maxwell AL, Gardiner E, Loxton NJ. Variables analysed of the total sample and in comparison of the sub-samples with and without food addiction FA. Statistical analyses were performed with Statistical Package for Social Science Software SPSS, IBM SPSS Statistics versions 25 and 26 [ 35 ].
t tests examined the differences between the sub-samples with and without FA in metric variables binge eating score, emotional eating score, the five FEV dimensions of eating behaviour, BMI, age, age at onset of obesity, stress level, degree of social support, weight loss during the programme after normal distribution has been tested graphically using Q-Q plots.
χ 2 tests examined differences in categorical variables prevalence of night eating, problematic consumption of the three food categories, sex, prevalence of other substance use, programme withdrawal rate.
To counteract alpha error cumulation, p values were adjusted using Bonferroni correction. In addition, multiple linear regression analysis tested possible determinants of FA. To further differentiate FA from binge eating, in a second step, the collective was divided into two new subgroups patients with exclusively FA without binge eating vs.
patients with exclusively binge eating without FA and these were compared as described above. Tables and figures were created in the spreadsheet Microsoft Excel version Table 1 shows the mean values of all analysed variables, including the differentiation in patients with and without FA, as well as the results of the inferential statistics.
No significant differences were found for sex, age, and BMI. Disinhibition, cognitive restraint, rigid and flexible control showed no significant differences.
A multiple linear regression analysis was conducted with the variables disinhibition, hunger, cognitive control, age, and BMI. The R 2 for the overall model was 0. These findings are demonstrated in Figure 1.
Figure 2 illustrates the overlap between FA and binge eating and night eating, respectively. The descriptive and analytical statistical key figures can be seen in online supplementary Table S2 for all online suppl. Comparison of patients with and without food addiction FA with regard to night eating a , emotional eating b , and binge eating c.
a , b Overlap of food addiction FA and night eating NE and binge eating behaviour BE , respectively, in a patient population with morbid obesity. Patients with FA descriptively consumed more foods rich in both carbohydrates and fat than patients without FA, although this was not statistically significant and had a small effect size.
There were no differences respective of foods containing carbohydrates or fat alone. The differences between the sub-samples with and without FA concerning all three food categories are illustrated in Figure 3. Comparison of patients with and without food addiction FA with regard to problematic food categories.
Stress level, social support, age at onset of obesity, BMI reduction during the weight loss programme, programme withdrawal rate, and prevalence of other substance use did not differ significantly between the two sub-samples.
No substances other than alcohol and smoking were reported. One quarter of the sample met the YFAS 2. This is consistent with other studies involving patients with pronounced obesity [ 11, 19 ].
The high prevalence among this sample of subjects with morbid obesity in contrast to lower prevalences in samples of healthy subjects indicates a considerable relevance of FA for the phenotype of some cases of obesity, but not all. However, three-quarters of the obesity cases in this sample remain not associated with FA.
In conclusion, for the majority of obesity cases, FA can apparently not serve as an aetiologic construct [ 36 ]. No statistically significant sex differences were observed between patients with and without FA, though descriptively, men had a higher prevalence than women.
This is unexpected as it is not in line with most previous studies, which concordantly found women exhibiting a higher prevalence of FA than men [ 14, 17, 21, 22, 26 ] or no sex difference at all [ 4 ].
However, the majority of these studies were conducted with normal-weight populations. A single study of individuals with obesity was found; it showed a descriptively higher prevalence in men [ 37 ]. According to previous studies on populations with both normal weight and obesity, it would have been expected that the group with FA would show a lower age [ 5, 22, 37 ].
However, our study results do not support this hypothesis, as the descriptive differences were not significant and had small effect size. The sample exhibited a mean BMI of No significant differences in BMI were observed between the sub-samples with and without FA, endorsing previous studies conducted in populations with obesity [ 23, 39, 40 ].
The lack of difference can be explained by the selection of the sample: all patients were participants of a weight reduction programme and were accordingly affected by pronounced obesity. It is important to note that the questionnaire data used is not suitable for diagnosing a substance use disorder SUD according to DSM criteria.
The prevalence of SUD according to DMS criteria is significantly lower in comparable populations of patients with morbid obesity 0. The current study observed significantly more distinct feelings of hunger, with a large effect size, among patients with FA in contrast to those without, supporting previous studies in however normal-weight populations [ 14, 21 ].
Moreover, hunger and disinhibition proved to be significant predictors for FA. In samples with obesity, previous studies found correspondingly higher levels of impulsivity [ 23, 40 ]. On the one hand, this is at odds with another study on a sample with obesity, which found an association between binge eating and cognitive restraint [ 42 ].
On the other hand, previous studies on normal-weight populations have found the same lack of effect [ 21, 43 ].
High grades of disinhibition and hunger as decisive elements of impulsivity [ 44 ] are suggestive of dysfunctional behavioural regulation mechanisms. Patients with FA seem to be more susceptible to disruptions in their planned eating, whether from external stimuli or internal, such as perceived hunger.
This might contribute essentially to the binge eating behaviour seen in FA. As previously stated, impulsivity is associated with binge eating disorder [ 45 ].
Previous studies have observed a relationship between low distress tolerance and both disinhibition and emotional eating [ 46 ]. In combination with the present findings, this suggests that dysfunctional emotional coping mechanisms associated with low distress tolerance could be a mediator between FA and disinhibition and hunger, respectively.
Patients with FA exhibited significantly higher emotional eating scores than patients without FA, with medium effect size, in line with previous studies on populations with obesity [ 27, 47 ].
These findings suggest that unpleasant feelings, such as fear, anger, sorrow, loneliness, sadness, and helplessness, can trigger uncontrolled excessive intake of food, as a means to dampen unpleasant emotional states. Given that not all individuals use food to regulate their emotions, the prerequisite for such behaviour might be disturbed emotional coping mechanisms.
As disturbances in emotional coping can obviously contribute decisively to the development of addictive-like eating behaviour, FA appears to hold features of behavioural addiction. The study at hand revealed significantly higher scores for binge eating behaviour in patients with FA in contrast to those without FA, with a large effect, in accordance with many previous studies on patients with obesity [ 23, 27, 48, 49 ].
Consequently, the uncontrolled consumption of excessively high amounts of food in a short time might be a decisive characteristic of not only binge eating disorder but of FA as well. This is also confirmed by our data: significant differences between the subgroups with and without FA emotional eating, night eating, hunger are not confirmed in the comparison of FA and binge eating.
Accordingly, these variables must not be interpreted as characteristics of FA alone but characterise binge eating as well. Despite this, binge eating and FA cannot be regarded the same as is shown by the wide range of the binge eating score in the sub-sample with FA.
There were as well some patients fulfilling the FA criteria while exhibiting very low binge eating scores. This is in line with previous research concluding that BED and FA might be considered as distinct clinical phenomena [ 15 ].
Regarding the lack of effect when comparing FA and binge eating, the relatively small sample size and composition of the collective in this study should also be considered. Significantly higher scores of binge eating behaviour in patients with FA lead to the hypothesis that FA might be characterised by eating to excess in a short period of time rather than perpetual food intake, so called grazing [ 15 ].
The high levels of disinhibition and hunger as decisive elements of impulsivity [ 44 ] may contribute significantly to the development of binge eating episodes. It would be of crucial interest to differentiate the manner of binges in FA and binge eating disorder [ 14 ].
This merits scrutiny in future research. The sub-sample with FA exhibited a significantly higher prevalence of night eating than the sub-sample without FA, supporting previous studies on populations with obesity [ 47, 48 ], albeit with a small effect. Consequently, it can be postulated that FA might be associated with difficulties in the maintenance of a circadian eating rhythm.
As previous studies, however in normal-weight populations, suggested [ 17, 51 ], patients with FA were assumed to have significantly more problems with foods containing both carbohydrates and fat than patients without FA.
However, this effect was only observed descriptively, without statistical significance, and with small effect size. The lack of a relevant difference in our study could be related to the small size of our sample and its composition. The aforementioned association of addictive eating behaviour and energy-dense food, as e.
Foods containing only carbohydrates or fat showed no relevant differences. These findings are consistent with studies on normal-weight individuals , which stated no association between FA and foods containing only carbohydrates [ 20 ]. Generalisability of the findings is limited due to the small number of subjects in relation to the large number of variables tested.
The results should be reviewed in future studies. Concerning binge eating this study is limited as the available data does not allow a full diagnosis of a clinically approved disorder according to DSM criteria but merely indicate binge eating behaviour.
The results are also limited with regard to emotional eating, as no validated construct was available to capture emotional eating. Instead, five questions from two questionnaires were combined into the emotional eating score, so that the two questionnaires may be confounded.
Future research should verify the results with validated tools. For this reason, the distinction between the food categories might be inaccurate, which could be relevant regarding the lack of significance of our results and should be further investigated in future studies.
Moreover, it would be of interest to examine in which context the problematic foods are consumed in the context of a meal, a snack, a binge eating episode , which was not captured by the present study.
The questionnaire-based trait FA can be considered as a sub-phenotype of obesity, occurring in approximately one-quarter of obesity cases. Dysfunctional emotional coping mechanisms associated with low distress tolerance were found to be significantly related to FA and should be suggested as therapeutic targets.
Behavioural interventions should include a bio-psycho-social model [ 52 ] and address social and cultural aspects that may promote pathological eating behaviour media, beauty ideals, affiliation, exclusion.
In addition, binge eating episodes were found to be characteristic for FA. The results point to the already stated overlap between FA and binge eating disorder. However, the existence of FA as a distinct entity phenomenon should not be excluded, as not all patients with FA exhibit binges.
The same applies to the question of a substance-related or behavioural component of FA. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation institutional and national and with the Helsinki Declaration of and its later amendments.
Written informed consent was obtained from participants prior to the study. Pia Schankweiler played the leading role in analysing the data.
Pia Schankweiler drafted the manuscript. All authors revised and approved the final version. All data generated or analysed during this study are included in this article and its supplementary material files.
Background addictionn Aims: It is assumed Obesihy a relevant subgroup of individuals experiences an addiction-like eating Obesity and food addiction Annd Addictioncharacterized by an impaired control over eating behaviour, emotional eating and food craving. Addictin Obesity and food addiction Insulin dosing guidelines Obesity and food addiction partially share common symptomatology with Binge-Eating-Disorder and High protein recipes Nervosa. The aim of this study was to investigate the prevalence cood Obesity and food addiction Addiction, general psychopathology, and associations with weight- and addiction-related constructs in individuals with overweight and obesity, who did not suffer from Binge-Eating-Disorder or Bulimia Nervosa. Food Addiction severity, depressive symptoms, alcohol use disorder, internet use disorder, psychological distress, impulsivity personality trait, impulsive and emotional eating behaviour, food related inhibitory control, weight bias internalization, and self-efficacy were assessed. Food Addiction was associated with higher BMI at baseline assessment, low self-esteem, impulsive and emotional eating behaviour, weight bias internalization, and deficits in food-related inhibitory control. In addition, correlations were found between Food Addiction and severity of depressive symptoms, internet use disorder, and psychological distress. Conclusion: A relevant subgroup of participants experiences Food Addiction even when controlling for Binge-Eating-Disorder and Bulimia Nervosa.Eating disorder adiction are dedicated helplines offering assistance, information, Obesity and food addiction support for individuals dealing with eating addictiom. Staffed Obesitj trained professionals, vood provide a safe space Obesihy discuss struggles, seek guidance, and Glucose metabolism pathways referrals Obesity and food addiction treatment options adviction emotional abd.
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Metabolic surgery profoundly influences gut microbial-host metabolic cross-talk. Gut 60 , — Li, M. Symbiotic gut microbes modulate human metabolic phenotypes. The total score ranges between 0 and , with higher scores indicating increased food related inhibitory control. Preliminary validation proposes a four-factor solution with the subscales Action Withdrawal AW, e. The subscale emotional eating of the German translation of the Dutch Eating Behaviour Questionnaire DEBQ, Van Strien et al. The original self-report questionnaire consists of 30 items. The subscale score ranges between 10 and 50 points. Good psychometric properties of the German version of the scale have been demonstrated by Nagl and colleagues Nagl et al. The German version of the Weight Bias Internalization Scale WBIS, Hilbert et al. The WBIS consists of 11 items which are rated on a seven-point scale ranging from strongly disagree 1 to strongly agree 7. The total score ranges between 11 and The German version showed good psychometric properties Hilbert et al. To measure self-efficacy, the General Self-Efficacy Scale SWE, Jerusalem and Schwarzer, was used. The self-report questionnaire consists of 10 items, each of it answered on a four-point scale ranging from not at all true 1 to exactly true 4 , yielding a total score between 10 and 40 points. The SWE showed good psychometric properties in a representative German sample Hinz et al. All analyses were conducted with IBM SPSS statistics for windows Version and Microsoft Excel Version Descriptive analyses were conducted using percentages and frequencies for categorical variables, as well as means and standard deviations for continuous variables. Chi-square distributions that compared categorical variables between groups FA vs. NFA were implemented as well as Bonferroni-adjusted independent t -tests to compare metrically scaled variables. Associations between metrically scaled variables were analysed using Pearson correlations. The study was carried out in accordance with the Declaration of Helsinki. The Institutional Review Board of the Ruhr-University Bochum approved the study Nr. All subjects were informed about the study and all provided written informed consent. Table 2 gives an overview about sociodemographic factors both of the total sample and the subsamples of individuals experiencing food addiction FA or not experiencing FA NFA. No differences between the subsamples FA vs. NFA regarding gender, age, BMI, marital status and education could be found. Table 4 illustrates results from independent t-Tests between the subsamples FA vs. NFA on psychosocial measurements and psychopathology. FA participants showed significantly higher FA symptom severity YFAS 2. Additionally, the GSI BSI was higher for FA compared to NFA participants, indicating higher psychological distress. Moreover, FA participants scored less on three of four FRIS subscales AW, AC and RS , indicating impairments in behavioural inhibitory control and increased reward sensitivity. The groups did not differ on the subscale DD, reflecting impulsive choices. Table 4. Psychopathology and weight- and addiction-related constructs FA vs. The main aim of the present study was to assess the prevalence of FA in a treatment-seeking sample of individuals with overweight or obesity and without comorbid BN or BED as previous studies did not control for these comorbid disorders. Notably, the higher prevalence rates in female participants might also be explained by a general tendency of women to over-report health problems compared to men Boerma et al. Our findings fit the assumption that the prevalence of FA is higher in individuals with overweight and obesity The lower prevalence rate in our study might therefore be due to the fact, that individuals suffering from BN or BED were excluded from participation. FA severity was associated with increased BMI, which is in line with findings of previous studies Pedram et al. A variety of studies reports associations between FA and SUDs Davis and Carter, ; García-García et al. In our study, AUD severity was not associated with FA. This might be because hazardous alcohol consumption was an exclusion criterion for participation, but the missing correlation could also be masked by the inverse relationship between AUD and BMI. However, in line with previous studies, FA was associated with severity of depressive symptoms and psychological distress Gearhardt et al. Although participants meeting the diagnostic criteria for major depression and AUD were excluded from participation, our results underline the strong relationship between FA symptomatology and mood disorders, and enlighten the high level of distress in individuals experiencing FA, which together might contribute to weight gain Bourdier et al. FA was linked to IUD severity. IUD is a behavioural addiction characterized by excessive internet usage and an impaired control over usage behaviour Young, Excessive internet usage is associated with unhealthy eating and sedentary behaviour and might subsequently aggravate FA symptomatology and contribute to weight gain Vandelanotte et al. Moreover, FA was linked to emotional eating and WBI and both were significantly higher in FA compared to NFA participants. There seems to be a shift from positive reinforcement to negative reinforcement in individuals experiencing FA regarding the consumption of palatable food Parylak et al. Given that palatable food can be both rewarding and stress reducing, food deprivation may lead to withdrawal i. In line with previous studies, self-efficacy was negatively correlated to FA symptom severity in our sample Burmeister et al. Low self-efficacy and high WBI are linked to lower physical activity and WBI predicts reduced odds of achieving weight-loss in individuals with overweight and obesity Hübner et al. Therefore, the reported associations between FA, WBI and self-efficacy fits prior observations that individuals experiencing FA suffer from weight cycling Gearhardt et al. It is assumed that the relationship between WBI and FA is moderated by emotional dysregulation, which should be further investigated Baldofski et al. Future studies might also consider assessing weight control or eating self-efficacy instead of global self-efficacy Linde et al. FA was associated with an impulsive eating behaviour and deficits in food-related inhibitory control. FA participants significantly differed from NFA participants in food-related impulsive actions action withdrawal and cancelation , as well as reward sensitivity. This indicates that individuals experiencing FA have more problems in resisting impulses towards disposable and rewarding food and might therefore need specific training elements to enhance weight loss Meule, a. Delay discounting was associated with FA symptom severity, but the subgroup of FA participants did not significantly differ from NFA participants on this subscale. This might be due to the fact that delay discounting is generally increased in individuals with obesity Mole et al. Interestingly, FA was not associated with the impulsivity personality trait. This is in contrast to prior studies indicating that FA, as well as other SUDs and EDs are associated with higher impulsivity traits Mobbs et al. Since BN, BES and AUD were exclusion criteria in our study, it might be possible, that overlapping symptoms with this disorders confounded prior results. Based on our results, we hypothesize that not a global disposition towards impulsive behaviour, but rather a learning process that food is rewarding and disposable, may contribute to the impulsive eating behaviour in FA participants. In our study, impulsivity personality trait, impulsive eating behaviour and food-related inhibitory control were measured using self-reporting questionnaires. Since self-reported and behavioural results regarding disinhibition of eating behaviour in individuals with obesity can differ, the results of our study should be further analysed using behavioural tasks Loeber et al. Furthermore, potential moderating factors like restrained eating or current mood should be considered Loeber et al. A particular strength of our study is that we analysed FA in a sample of individuals with overweight and obesity who did not suffer from eating disorders, which was verified by questionnaire and structured interview two stage design. However, when interpreting the findings of the present study a few limitations should be acknowledged. It can be assumed that the prevalence of FA would have been higher when including these participants, since FA is reported to be increased in individuals experiencing extreme obesity ca. In addition, since AUD and major depression were exclusion criteria, the reported associations between FA, AUD severity and severity of depressive symptoms might be confounded. Since the risk for FA increases in polyabusers, the exclusion of individuals suffering from hazardous alcohol consumption might subsequently cause a lower prevalence of FA in our study Tinghino et al. Finally, a broad test battery, i. Still, our conclusions are based on results from self-reporting questionnaires and different results may be observed when using behavioural measurements as for example reported by Loeber et al. In addition, typical pre-test self-report biases are known, which might have further influenced our results Aiken and West, With a view to a potential inclusion of FA in the diagnostic catalogues, it would make sense to develop and use objective diagnostic assessment tools, like structured interviews Gearhardt and Hebebrand, ; Hebebrand and Gearhardt, The interpretation of our results is aggravated due to our cross-sectional study design, i. It would subsequently be meaningful to verify the results in longitudinal studies, i. Summing up, our results support the view that, even when adjusting for BN and BED, a relevant subgroup of individuals with overweight and obesity experiences an addiction-like eating behaviour. This subgroup differs from non-addictive eaters on several weight- and addiction-related factors, like emotional eating, WBI, and impulsivity. Moreover, individuals experiencing FA suffer from depressive symptoms, addictive disorders and psychological distress. In sum, these impairments may contribute to weight gain. If so, our results underline that the lack of an officially approved FA diagnosis might currently cause an insufficient clinical care for individuals experiencing an addiction-like eating behaviour. It might therefore be reasonable to investigate the effect of FA on weight loss when adjusting for eating disorders and to further implicate addiction-specific therapeutic elements in WLPs to enhance weight loss and prevent weight regain in this subgroup. The datasets presented in this article are not readily available because data will be made available only on reasonable request. Requests to access the datasets should be directed to magdalena. pape rub. The studies involving human participants were reviewed and approved by The Institutional Review Board of the Ruhr-University Bochum Nr. MP: conceptualisation, acquisition of data, formal analysis, interpretation of data, and writing — original draft. SH: conceptualisation, writing- original draft, and study supervision. SS and CS: study design, acquisition of data, and review and editing. TF: acquisition of data and review and editing. JW: study design, study supervision, and review and editing. SS-L: study design and conceptualisation, study supervision, and review and editing. All authors contributed to the article and approved the submitted version. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. 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Sanmiguel for her contributions in making editorial suggestions to the gut-directed therapies section of this review and C. Liu for invaluable editorial services. has been supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases DK, DK and DK Oppenheimer Family Center for Neurobiology of Stress and Resilience, Ingestive Behavior and Obesity Program, University of California Los Angeles, Los Angeles, CA, USA. David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA. Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA, USA. Ahmanson-Lovelace Brain Mapping Center at University of California Los Angeles, University of California Los Angeles, Los Angeles, CA, USA. You can also search for this author in PubMed Google Scholar. Correspondence to Emeran A. serves on the scientific advisory boards of Amare, APC Microbiome Ireland, Axial Biotherapeutics, Bloom Science, Danone, Mahana Therapeutics, Pendulum and Viome. and V. declare no competing interests. Brown, E. Jerlhag, P. Kenny and L. Leggio for their contribution to the peer review of this work. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. An interdisciplinary field of study that focuses on complex interactions within multiple biological systems, rather than focusing on individual mechanisms. The extensive network of neurons in the extended reward network that depend on dopamine as the primary neurotransmitter for reward-related processing. Processes associated with reward sensitivity, motivation, interoceptive awareness, stress reactivity and self-control. Region of the basal ganglia and a key hub for the core reward system, responsible for many dopaminergic processes, especially those related to pleasure, motivation and aversion. Key region of the midbrain that houses the dopaminergic cell bodies that project to all regions of the core and extended reward network. The brain network responsible for monitoring the homeostatic state of the body to make adaptive adjustments to real or expected disturbances in homeostasis through the autonomic nervous system and behavioural responses. The extensive communication network between the cortex, which houses the extended reward network including the frontal cortex and insula and the striatum, which houses the core reward network nucleus accumbens, basal ganglia. Dietary fibre or other substrates that can only be digested by commensal gut microorganisms, thereby promoting gut microbiota diversity and health. Behaviours used to cope with stressful situations to alleviate the stress or symptoms, but are not necessarily healthy and do not address the core cause of the stress. Stress originating from the environment that is sufficient to cause dysregulation of homeostatic responses and physical or psychological symptoms. The most widely used scale for perceived stress is the Perceived Stress Scale. Reprints and permissions. Brain—gut—microbiome interactions in obesity and food addiction. Nat Rev Gastroenterol Hepatol 17 , — Download citation. Accepted : 24 June Published : 27 August Issue Date : November Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Applied Microbiology and Biotechnology Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily. Skip to main content Thank you for visiting nature. Subjects Gastrointestinal models Obesity. Abstract Normal eating behaviour is coordinated by the tightly regulated balance between intestinal and extra-intestinal homeostatic and hedonic mechanisms. Key points Food addiction refers to maladaptive ingestive behaviours resulting from a shift from primarily homeostatic to hedonic regulatory mechanisms of food intake; this shift reflects alterations at all levels of the brain—gut—microbiome BGM axis. Access through your institution. Buy or subscribe. Change institution. Learn more. Google Scholar Mancini, M. PubMed PubMed Central Google Scholar Zhang, Y. CAS PubMed PubMed Central Google Scholar Heymsfield, S. CAS PubMed Google Scholar Osadchiy, V. CAS PubMed Google Scholar Mayer, E. CAS PubMed Google Scholar Keita, A. CAS PubMed Google Scholar Yu, M. CAS PubMed Google Scholar Moreira, C. CAS PubMed PubMed Central Google Scholar Houlden, A. 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Statistical analyses were performed with Statistical Package for Social Science Software SPSS, IBM SPSS Statistics versions 25 and 26 [ 35 ]. t tests examined the differences between the sub-samples with and without FA in metric variables binge eating score, emotional eating score, the five FEV dimensions of eating behaviour, BMI, age, age at onset of obesity, stress level, degree of social support, weight loss during the programme after normal distribution has been tested graphically using Q-Q plots. χ 2 tests examined differences in categorical variables prevalence of night eating, problematic consumption of the three food categories, sex, prevalence of other substance use, programme withdrawal rate. To counteract alpha error cumulation, p values were adjusted using Bonferroni correction. In addition, multiple linear regression analysis tested possible determinants of FA. To further differentiate FA from binge eating, in a second step, the collective was divided into two new subgroups patients with exclusively FA without binge eating vs. patients with exclusively binge eating without FA and these were compared as described above. Tables and figures were created in the spreadsheet Microsoft Excel version Table 1 shows the mean values of all analysed variables, including the differentiation in patients with and without FA, as well as the results of the inferential statistics. No significant differences were found for sex, age, and BMI. Disinhibition, cognitive restraint, rigid and flexible control showed no significant differences. A multiple linear regression analysis was conducted with the variables disinhibition, hunger, cognitive control, age, and BMI. The R 2 for the overall model was 0. These findings are demonstrated in Figure 1. Figure 2 illustrates the overlap between FA and binge eating and night eating, respectively. The descriptive and analytical statistical key figures can be seen in online supplementary Table S2 for all online suppl. Comparison of patients with and without food addiction FA with regard to night eating a , emotional eating b , and binge eating c. a , b Overlap of food addiction FA and night eating NE and binge eating behaviour BE , respectively, in a patient population with morbid obesity. Patients with FA descriptively consumed more foods rich in both carbohydrates and fat than patients without FA, although this was not statistically significant and had a small effect size. There were no differences respective of foods containing carbohydrates or fat alone. The differences between the sub-samples with and without FA concerning all three food categories are illustrated in Figure 3. Comparison of patients with and without food addiction FA with regard to problematic food categories. Stress level, social support, age at onset of obesity, BMI reduction during the weight loss programme, programme withdrawal rate, and prevalence of other substance use did not differ significantly between the two sub-samples. No substances other than alcohol and smoking were reported. One quarter of the sample met the YFAS 2. This is consistent with other studies involving patients with pronounced obesity [ 11, 19 ]. The high prevalence among this sample of subjects with morbid obesity in contrast to lower prevalences in samples of healthy subjects indicates a considerable relevance of FA for the phenotype of some cases of obesity, but not all. However, three-quarters of the obesity cases in this sample remain not associated with FA. In conclusion, for the majority of obesity cases, FA can apparently not serve as an aetiologic construct [ 36 ]. No statistically significant sex differences were observed between patients with and without FA, though descriptively, men had a higher prevalence than women. This is unexpected as it is not in line with most previous studies, which concordantly found women exhibiting a higher prevalence of FA than men [ 14, 17, 21, 22, 26 ] or no sex difference at all [ 4 ]. However, the majority of these studies were conducted with normal-weight populations. A single study of individuals with obesity was found; it showed a descriptively higher prevalence in men [ 37 ]. According to previous studies on populations with both normal weight and obesity, it would have been expected that the group with FA would show a lower age [ 5, 22, 37 ]. However, our study results do not support this hypothesis, as the descriptive differences were not significant and had small effect size. The sample exhibited a mean BMI of No significant differences in BMI were observed between the sub-samples with and without FA, endorsing previous studies conducted in populations with obesity [ 23, 39, 40 ]. The lack of difference can be explained by the selection of the sample: all patients were participants of a weight reduction programme and were accordingly affected by pronounced obesity. It is important to note that the questionnaire data used is not suitable for diagnosing a substance use disorder SUD according to DSM criteria. The prevalence of SUD according to DMS criteria is significantly lower in comparable populations of patients with morbid obesity 0. The current study observed significantly more distinct feelings of hunger, with a large effect size, among patients with FA in contrast to those without, supporting previous studies in however normal-weight populations [ 14, 21 ]. Moreover, hunger and disinhibition proved to be significant predictors for FA. In samples with obesity, previous studies found correspondingly higher levels of impulsivity [ 23, 40 ]. On the one hand, this is at odds with another study on a sample with obesity, which found an association between binge eating and cognitive restraint [ 42 ]. On the other hand, previous studies on normal-weight populations have found the same lack of effect [ 21, 43 ]. High grades of disinhibition and hunger as decisive elements of impulsivity [ 44 ] are suggestive of dysfunctional behavioural regulation mechanisms. Patients with FA seem to be more susceptible to disruptions in their planned eating, whether from external stimuli or internal, such as perceived hunger. This might contribute essentially to the binge eating behaviour seen in FA. As previously stated, impulsivity is associated with binge eating disorder [ 45 ]. Previous studies have observed a relationship between low distress tolerance and both disinhibition and emotional eating [ 46 ]. In combination with the present findings, this suggests that dysfunctional emotional coping mechanisms associated with low distress tolerance could be a mediator between FA and disinhibition and hunger, respectively. Patients with FA exhibited significantly higher emotional eating scores than patients without FA, with medium effect size, in line with previous studies on populations with obesity [ 27, 47 ]. These findings suggest that unpleasant feelings, such as fear, anger, sorrow, loneliness, sadness, and helplessness, can trigger uncontrolled excessive intake of food, as a means to dampen unpleasant emotional states. Given that not all individuals use food to regulate their emotions, the prerequisite for such behaviour might be disturbed emotional coping mechanisms. As disturbances in emotional coping can obviously contribute decisively to the development of addictive-like eating behaviour, FA appears to hold features of behavioural addiction. The study at hand revealed significantly higher scores for binge eating behaviour in patients with FA in contrast to those without FA, with a large effect, in accordance with many previous studies on patients with obesity [ 23, 27, 48, 49 ]. Consequently, the uncontrolled consumption of excessively high amounts of food in a short time might be a decisive characteristic of not only binge eating disorder but of FA as well. This is also confirmed by our data: significant differences between the subgroups with and without FA emotional eating, night eating, hunger are not confirmed in the comparison of FA and binge eating. Accordingly, these variables must not be interpreted as characteristics of FA alone but characterise binge eating as well. Despite this, binge eating and FA cannot be regarded the same as is shown by the wide range of the binge eating score in the sub-sample with FA. There were as well some patients fulfilling the FA criteria while exhibiting very low binge eating scores. This is in line with previous research concluding that BED and FA might be considered as distinct clinical phenomena [ 15 ]. Regarding the lack of effect when comparing FA and binge eating, the relatively small sample size and composition of the collective in this study should also be considered. Significantly higher scores of binge eating behaviour in patients with FA lead to the hypothesis that FA might be characterised by eating to excess in a short period of time rather than perpetual food intake, so called grazing [ 15 ]. The high levels of disinhibition and hunger as decisive elements of impulsivity [ 44 ] may contribute significantly to the development of binge eating episodes. It would be of crucial interest to differentiate the manner of binges in FA and binge eating disorder [ 14 ]. This merits scrutiny in future research. The sub-sample with FA exhibited a significantly higher prevalence of night eating than the sub-sample without FA, supporting previous studies on populations with obesity [ 47, 48 ], albeit with a small effect. Consequently, it can be postulated that FA might be associated with difficulties in the maintenance of a circadian eating rhythm. As previous studies, however in normal-weight populations, suggested [ 17, 51 ], patients with FA were assumed to have significantly more problems with foods containing both carbohydrates and fat than patients without FA. However, this effect was only observed descriptively, without statistical significance, and with small effect size. The lack of a relevant difference in our study could be related to the small size of our sample and its composition. The aforementioned association of addictive eating behaviour and energy-dense food, as e. Foods containing only carbohydrates or fat showed no relevant differences. These findings are consistent with studies on normal-weight individuals , which stated no association between FA and foods containing only carbohydrates [ 20 ]. Generalisability of the findings is limited due to the small number of subjects in relation to the large number of variables tested. The results should be reviewed in future studies. Concerning binge eating this study is limited as the available data does not allow a full diagnosis of a clinically approved disorder according to DSM criteria but merely indicate binge eating behaviour. The results are also limited with regard to emotional eating, as no validated construct was available to capture emotional eating. Instead, five questions from two questionnaires were combined into the emotional eating score, so that the two questionnaires may be confounded. Future research should verify the results with validated tools. For this reason, the distinction between the food categories might be inaccurate, which could be relevant regarding the lack of significance of our results and should be further investigated in future studies. Moreover, it would be of interest to examine in which context the problematic foods are consumed in the context of a meal, a snack, a binge eating episode , which was not captured by the present study. The questionnaire-based trait FA can be considered as a sub-phenotype of obesity, occurring in approximately one-quarter of obesity cases. Dysfunctional emotional coping mechanisms associated with low distress tolerance were found to be significantly related to FA and should be suggested as therapeutic targets. Behavioural interventions should include a bio-psycho-social model [ 52 ] and address social and cultural aspects that may promote pathological eating behaviour media, beauty ideals, affiliation, exclusion. In addition, binge eating episodes were found to be characteristic for FA. The results point to the already stated overlap between FA and binge eating disorder. However, the existence of FA as a distinct entity phenomenon should not be excluded, as not all patients with FA exhibit binges. The same applies to the question of a substance-related or behavioural component of FA. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation institutional and national and with the Helsinki Declaration of and its later amendments. Written informed consent was obtained from participants prior to the study. Pia Schankweiler played the leading role in analysing the data. Pia Schankweiler drafted the manuscript. CrossRef Full Text Google Scholar. Avena, N. PubMed Abstract CrossRef Full Text Google Scholar. Baldofski, S. Weight bias internalization, emotion dysregulation, and non-normative eating behaviors in prebariatric patients. 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| Key points | Antibiotics Obesity and food addiction early Obeaity dysbiosis and the damage anr. Ulrich-Lai, Y. USA— Obesity, it seems, is not caused by a lack of willpower. Made a searching and fearless moral inventory of ourselves. |
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