Obesity has been recognized as one of the major public health problems in the world.1 In the United States, overeating and obesity have been reported by the Journal of the American Medical Association as the cause of 280 184 deaths per year. According to me Centers for Disease Control and Prevention (CDC), the prevalence of obesity among US adults is 19.8%, which reflects a 61% increase since 1991. A total of 38.8 million American adults meet the classification of obesity, defined as having a body mass index score of 30 or more.1 Researchers have come to a consensus that obesity is a disease but often debate whether it is related to depression, personality disorders, or addictions. Obesity is a major problem among children, adolescents and adults. As Dr. Miller and her colleagues describe in this issue of Psychiatric Annals ., once established in childhood obesity tends to continue and compromise psychosocial development and health.
Obesity not only shares a leading position on the CDCs cause of premature and preventable death list wim tobacco, alcohol, second-hand smoke but may share a common neurobiology. Dr. Wang and the work of the Brookhaven group has certainly suggested that the brain's dopamine system for reinforcement projecting from the ventral tegmental area to nucleus aceumbens, reacts to overeating as it does to cocaine or alcohol.
Addictions, obesity, and eating disorders have common features and natural history. As reviewed by Dr. Jacobs and colleagues, "If it quacks, it must be a duck." Certainly bingeeating disorders look, sound and feel like addictions. Clinical experience has taught us that denial, the cornerstone of the addiction intervention or motivational interviewing, is equally active in obesity, anorexia, and bulimia. Eating disordered patients and those with addictions often believe they are fine. The oft-quoted line that, "American society is obsessed wim body shape and size" may be true but certainly does not explain a 5 foot tall women weighing 250 pounds. The severity of illness denial may assume delusional proportions. As the addict or obese or person with an eating disorder is closer and closer to death, he or she moves farther and farther from accepting help. Extreme interventions, various forms of coercive and involuntary treatment, are used in both types of disorders. The staff feels as though it is a struggle for survival and often it is. Addictions staff find patients with severe eating disorders to resemble addicts and respond to interventions and treatment as if they were addicts. Overeaters anonymous and many popular weight loss programs share numerous common features with addiction treatment modalities. Not surprisingly, addictions and eating disorders have the other comorbidity. Binge eating and bulimics are often comorbid for abuse and addiction, and drug addicts frequently forget to eat at all. These diseases may have different "substances" but they have a great deal in common.
Overeating and obesity require a new look as important psychiatric and addictive diseases that respond best to a combination of psychiatric, addiction, and self-help group therapies. Unfortunately, in both diseases death may come before recovery. Addicts, even physician addicts, use dirty needles, and have lifestyles where long life is more a salutation than a reality. Overeating resulting in diabetes or death is now more common than at any time in our past. Psychiatric approaches have often been limited to treating comorbidity or evaluating the morbidly obese patient for bariatric surgery suitability. Adding dieticians, exercise therapists, and psychiatrists to addiction treatment modalities has appeared to be an alternative to fad diets and treating one or another symptom. Weight management should be considered as part of me treatment program of addicts, as reviewed by Dr. Hogdkin, but also in the general psychiatric treatment.
Among the questions asked by experts is what drives overeating, a behavior mat compromises quality of life and survival itself. Clearly, this question and an obvious answer have been the critical theme of addiction research for the past 30 years. Drugs are taken for the positive, brain rewarding effects. Drugs are taken at the expense of short and long-term health, relationships, and employment. Drugs of abuse are thought to interact with brain systems normally used to support and encourage species survival. Food reward is at the top of the list of relevant pathways that drugs of abuse access. Amphetamine, cocaine, ecstasy (3,4-methylene-N-dioxymethylamphetamine [MDMA]), and tobacco are taken for meir reinforcing properties but also to produce changes in appetite and weight loss. On campus, we have seen young women who smoke tobacco cigarettes, drink cocaine and water, or take small doses of MDMA for weight control. Other drugs have significant effects on appetite and weight. Drugs of abuse may compete with food for unimpeded access to brain centers important in food and drug reward. The 1960s and '70s are evidence enough that drugs of abuse are compatible with sexual activity. Sex, drugs, and rock 'n roll, the mantra of that time, suggests the compatibility and possible synergy.
Our work suggests that Thanksgiving is the single day of the year with the least amount of drug use. Who binges on turkey and then shifts focus to drug taking? Overeating has an inhibitory effect on illicit drug taking. Bariatric surgery candidates with body weights of 300, 400, and above have as a group the least amount of drug use of any patients we see in our clinics. This important relationship is supported by addiction treatment professionals who often encourage recovering people to eat and even over-eat. The clinical treatment and recovery pearl worth remembering is me HALT acronym: Never get too Hungry, too Angry, too Lonely, or too Tired; or your chances of relapse are increased.
Almost a decade ago, we reported on the similarities of overeating and obesity to classical addictions. Since that time neuroimaging studies like those reported here by Dr. Wang have supported the hypothesis that loss of control over eating and obesity produce changes in me brain that are similar to those produced by drugs of abuse. Drugs of abuse and food appear to share many of the same brain pathways as substrates. Drug users and addicts refer to "hunger" for their drug. As reviewed by Dr. Lui and colleagues at the Brain Institute, applying functional magnetic resonance imaging research methodologies to the problem of obesity, hunger, and satiety may offer hope for understanding and the development of common treatments.
Clinical evidence and basic science experience and data support the hypomesis that obesity, bingeeating disorder, and bulimia nervosa can be substance abuse disorders. Biological and psychiatric treatment approaches are improving rapidly and may soon allow for specific treatments to be available for bingeeating disorder, bulimia nervosa, obesity, and anorexia. Some of the long-term treatment approaches share many features with the residential treatment of addictions.
1. Gold MS. Are eating disorders addictions? Presented at: American Society of Addiction Medicine 33rd Annual Medical Scientific Conference, Symposium 8; April 27, 2002; Atlanta, Ga.
2. Centers for Disease Control and Prevention. Prevelance of obesity among U.S. adults, by characteristics. Available: http: / / www.cdc.gov / nccdphp / dnpa / obesity / trend / prev_char. htm. Accessed December 2002.