Cooccuring Eating and Substance Use Disorders

Dr. David Wiss

October 30, 2022

Addictions

Toni: in this conversation, I'm thinking about friends, family members, you know, people I know who have had eating disorders and then get over that and later end up with a substance use disorder, or substance abuse disorder first where they manage that and then an eating disorder. My throat is kind of like “oh” because I'm picturing all these people whom I love who have gone through this. Feels like a spiral, right? But there's a relationship there and we're just curious do you see that they typically go in hand in hand or is it just a predisposition, or is it that dopamine thing? What can you tell us here?

 Dr. David Wiss: Such a good question and I've been asking the same question for many years and trying to learn more about the co-occurrence and overlap of eating disorders and substance use disorders. The data suggests that it could be anywhere as high as 50% overlap [1–6]. 

But I think an important point is a point that we made earlier about disordered eating versus full-blown clinically significant eating disorders. Someone that has a history of addiction has altered neurobiology which makes them more susceptible to reward-based processes. The brain assigns more value to things that are rewarding and remember that rewarding substances or behaviors are important for reducing negative affect.

Therefore, the brain registers it as a survival-promoting behavior. So, for someone that grew up with heavy drug addiction or alcohol use disorder, once they get sober it's very predictable that there's going to be some dysfunctional eating behavior and that might play out with binge eating, night eating, etc. and this can have a negative effect on body image. 

And so that's one example of the overlap. But then someone could also make the argument that chronic exposure to highly palatable foods during their childhood is what set them up for addiction-like processes. And that argument is very valid and hasn't been studied. 

If you think about this addiction epidemic that we're in if you think about the growth of highly palatable foods starting in the early 1980 and then living in a world. Side note: I'm also very interested in exposure to highly rewarding food during pregnancy and the potential implications for that to program the reward pathways of the offspring. We've seen that in animal models [7].

 So as the food environment is changing and there's more susceptibility to addictions there's a heightened level of stress, trauma, and adversity in the world and then you bring in all the other addictions with tech and phones and it’s a mental health crisis. The brain is just now set up for addiction-like processes across the board. People are way more impulsive, have much less attention, etc.

So, a lot of people get into eating disorder recovery and then cross into alcohol or drugs, or food. And there's certainly a role for stimulants that can be used for weight suppression in this conversation. We see appetite-suppressing drugs as well as appetite-suppressing medications being abused for weight management purposes. This can really impact one’s relationship with food. 

So yes, they cluster and they cooccur. I often find myself very curious about which one comes first. But to our previous points and I think a major theme of today is that trauma is certainly an antecedent to both.

And there are many people that would look at trauma as the real driver of the behavioral health issues and that the addiction and the eating disorder are just downstream manifestations of early life trauma.

If you’ve experienced overlapping eating and substance use disorders, nutrition is particularly important for you. It may be the key to the next chapter of your recovery, particularly if anxiety and/or depression are present. You can eat food for mood and brain health, without being restrictive and giving in to diet culture. You just have to find the right treatment team! 

References

1. Wiss D. Clinical Considerations of Ultra-processed Food Addiction Across Weight Classes: an Eating Disorder Treatment and Care Perspective. Curr Addict Reports. Published online 2022:1-13. doi:10.1007/s40429-022-00411-0

2. Wiss DA, Brewerton TD. Incorporating food addiction into disordered eating: the disordered eating food addiction nutrition guide (DEFANG). Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2017;22(1):49-59. doi:10.1007/s40519-016-0344-y

3. Wiss DA, Waterhous TS. Nutrition Therapy for Eating Disorders, Substance Use Disorders, and Addictions. In: Eating Disorders, Addictions and Substance Use Disorders, Research, Clinical and Treatment Perspectives. Springer; 2014:509-532. doi:10.1007/978-3-642-45378-6_23

4. Wiss D, Brewerton T. Separating the Signal from the Noise: How Psychiatric Diagnoses Can Help Discern Food Addiction from Dietary Restraint. Nutrients. 2020;12(10):2937. doi:10.3390/nu12102937

5. Wiss DA, Avena N, Rada P. Sugar Addiction: From Evolution to Revolution. Frontiers in Psychiatry. 2018;9:545. doi:10.3389/fpsyt.2018.00545

6. Wiss DA. The Role of Nutrition in Addiction Recovery: What We Know and What We Don’t. Elsevier. Published online 2019. doi:10.1016/b978-0-323-54856-4.00002-x

7. Wiss DA, Criscitelli K, Gold M, Avena N. Preclinical evidence for the addiction potential of highly palatable foods: Current developments related to maternal influence. Appetite. 2017;115:19-27. doi:10.1016/j.appet.2016.12.019