Addiction Medicine Made Easy | Fighting back against addiction

Weight Loss Surgery Doesn't Treat Food Addiction

• Casey Grover, MD, FACEP, FASAM

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Dr. Casey Grover shares his personal struggle with food addiction and binge eating while exploring the science behind why certain foods trigger addictive behaviors in the brain. He examines how the food industry deliberately engineers products to maximize pleasure and consumption through carefully calibrated combinations of sugar, fat, and salt.

• Food addiction involves an intense dopamine response to certain foods that varies between individuals based on genetic predisposition
• The food industry uses "bliss point" science to make products as addictive as possible
• Ultra-processed foods make up over half the average American diet despite increasing risks of various diseases
• Eating disorders (anorexia, bulimia, binge eating) are mental health conditions where food behaviors are merely the symptoms
• Treatment options include SSRIs, topiramate, naltrexone/bupropion combinations, and potentially GLP-1 medications
• Weight loss surgery fails to address the underlying mental health aspects of food addiction
• Dr. Grover's personal experience with naltrexone showed how it made previously pleasurable foods taste "flat"

If you found this episode helpful, please consider supporting Central Coast Overdose Prevention (https://ccodp.org/) and the work we do to treat addiction and prevent overdoses. Together we can improve how addiction is treated and save lives.

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started. Today we are going to be speaking about addictive behaviors around eating and food. We've covered this topic once before, about 18 months ago, and I was asked to speak about it again recently, so I updated my slides from the previous lecture and then I recorded myself presenting it and I've turned it into a podcast episode to share with all of you.

Speaker 1:

I do treat behavioral addictions in my practice and I have a few patients who I treat for binge eating and addictive behaviors towards food. And it's an interesting addiction because we must eat to survive and yet food is a big problem for the person with binge eating or food addiction. Compare that to alcohol. No one needs to drink alcohol, so stopping it isn't a big deal. As you will hear, this is a very emotional topic for me, given my own lived experience. A little background on the topic before we start. First of all, food addiction is not recognized as an actual diagnosis, but I found one definition of it on Wikipedia that I really liked, which is, quote it involves compulsive consumption of palatable foods, leading to negative health consequences and psychological dependence. End quote. In terms of actual diagnoses, the diagnoses that most fit this behaviors are binge eating disorder and bulimia. I begin the lecture with a review of the brain chemistry behind food addiction, but when I went back and listened to the episode when I was editing it, I realized that I could have been more clear in explaining this. So I will provide some clarification about the brain chemistry behind food addiction before we start about the brain chemistry behind food addiction. Before we start. Much of addiction involves the brain's reward center not working correctly.

Speaker 1:

We've talked about dopamine many times on this podcast, but let's just review it a little bit. When something feels good, like a hug from a friend, buying a new car or the taste of a sweet strawberry, that's the brain releasing dopamine into the pleasure centers of the brain. That release of dopamine into the pleasure center of the brain is what actually gives us that good feeling. Addiction often involves a person getting an intense release of dopamine after they use a substance such as heroin or alcohol, and that intense feeling of dopamine is what makes them do it again and leads to compulsive use With food. As you will hear, there are two issues. Eating tasty food results in the release of dopamine in the pleasure centers of everyone's brain. That's what makes the food actually taste good and makes eating enjoyable. But some people taste good and makes eating enjoyable. But some people, likely based on a genetic predisposition, release more dopamine when they eat tasty foods as compared to the average person, and this makes the food intensely pleasurable, which can lead to addictive behaviors around food, which usually shows up as compulsive consumption of food, such as binge eating, usually shows up as compulsive consumption of food, such as binge eating. And second, as I go into detail in this podcast episode, the food industry is engineering food to be more addictive by finding which preparations of food release the most dopamine and therefore make us eat a lot of it.

Speaker 1:

I apologize if this introduction makes the first part of my lecture a little bit redundant, but I wanted to make sure we all understood the brain chemistry of how food can be addictive. And with that, here we go. Okay, so I'm going to talk about addiction around food, specifically addictive behaviors with food and I'm going to share a part of my story. So people always ask me you know, dr Grover, you seem to understand addiction so well what was your addiction? And mine was food.

Speaker 1:

I used to binge eat, and this is me, my senior year in high school as captain of the football team, and that's when it started, and number nine on the screen was one of our running backs and I ended up playing line and he was running the ball and he fell and he landed on my right knee and it buckled and I tore a ligament in my knee and minus maybe like a minor injury. In middle school I had never taken a break from sports and I'll never forget. I had never taken a break from sports and I'll never forget. I was doing math, homework and eating a snack and the thought came to me well gosh, if you're not practicing football and working out all the time, maybe you shouldn't eat that. And from that thought my anxiety around food began no-transcript. And so, yeah, I have some lived experience here that I can share with you.

Speaker 1:

Now, as a doctor, I'm always trying to learn, and this is a really wonderful book. It's called Dopamine Nation and it was written by a addiction doctor at Stanford named Anna Lemke, and she talked about treating one of her patients with alcohol addiction with naltrexone. And you guys remember we've talked about naltrexone. It blocks opiates and the pleasure chemicals that get released when we use drugs and alcohol include our endorphins, and so the naltrexone makes alcohol less pleasurable for some people. And Dr Lemke had one of her patients who loved bacon and he had to stop his naltrexone because it made bacon not taste good.

Speaker 1:

And I wanted to see what would happen if I took naltrexone. So I called my friend who's a pharmacist and got some and, interestingly, when I took naltrexone, food stopped tasting good. Chocolate wasn't good, coffee was totally different and a lot of the foods that I loved just were flat. And my brain, when I eat sweet things, releases more dopamine and endorphins than the average person, which is what predisposed me to binge eating, and that's part of what we're going to talk about today. So this is a part of a lecture that I gave at a school that wanted me to talk about eating for students, and a lot of what I'm going to share over the next 30 minutes or so.

Speaker 1:

I've learned over years of research as a physician, combined with my personal experience, having lived with an eating disorder. So I'm going to ask the first question, which is can food be addictive? And this is a fantastic book written about food addiction. I don't like the title because I don't like the J word, but, just to say it, the title of the book is Food Junkies. I don't like the J word because it's very judgmental.

Speaker 1:

But yes, some people when they get sugar, they get an intense pleasure response and I am one of them and it's usually some combination of sugar, fat and salt that triggers that pleasure response. And you all know this with addiction, right? One person drinks alcohol and is like, yeah, I don't really feel anything. The next person drinks a couple of shots and is just like, oh my gosh, I feel so much better. I love this feeling. It's largely genetic About half of our risk of addiction is genetic and some people, like myself, have an intense pleasure response to foods.

Speaker 1:

Now let's look actually at some of the dopamine levels to support this. So this is a chart looking at the different amounts of dopamine that are released by different substances amphetamine, cocaine, morphine, nicotine and ethanol. And if you take a look, morphine, nicotine and ethanol all release a little bit and then the stimulants are much more stimulated. But this likely represents an average, meaning that for some people, when they have that genetic predisposition to alcohol addiction, those dopamine levels are way higher and for someone who doesn't, those dopamine levels might be lower. I found another chart that looks at how much dopamine is released by cheeseburgers compared to sex, nicotine, cocaine and meth, and you can see that the amount of dopamine released by a cheeseburger is not that far off from nicotine. And if you can see from the last slide, alcohol, nicotine and morphine all release similar amounts of dopamine and so you could almost say well, yeah, a cheeseburger is pretty intense, right, it's got all that salt. Mcdonald's will actually add sugar to them and then we obviously have the fat and oils. A cheeseburger for the average person's actually going to release a fair amount of dopamine.

Speaker 1:

And from this we're going to pivot to talking about how the food industry engineers food to make them more pleasurable. I would argue if you redid this chart and you did carrots, sex, nicotine, cocaine and meth, the dopamine response would be a lot less with carrots. Carrots don't really have much fat or salt. They have a little bit of sugar. That's natural in them. But different foods are going to release different amounts of dopamine for everyone, and then, for people like me who have that predisposition to binge eating, certain foods are going to release even more dopamine and, as we all know, dopamine is the chemical in our brains that makes us feel good and reinforces addiction. So this is another great book called the Way we Eat Now, and I am going to lay out the case that food is actually being engineered to be more addictive to increase profit. The three things that we all find pleasurable when we eat are sugar, fat and salt. We all have our individual tastes, but by manipulating the food, we can actually make it more pleasurable.

Speaker 1:

This is a podcast recorded on the radio show Fresh Air by the National Public Radio Service that actually gives a background on how the food industry does this, and this is how the food industry looks at it. If we make our food taste good, people will eat more of it, want more of it, buy more of it, and all of that makes us more money. Now you might be wondering how does the food industry do this? And it turns out they actually use a lot of scientific research. This screenshot is from a company that provides advice and guidance and best research to the food companies and take a look at this.

Speaker 1:

The science of craveability, decoding the senses Sensory science explains how the senses come together to create a cravable eating experience. Let's unpack that. So when I, as an addiction doctor, see my patients, I ask you how are you doing? Are you having any cravings? Cravings are a bad thing, right? If we think about addiction, what is it? It's three things cravings, compulsive use and consequences. So the food industry is actually tapping in To the same circuits of our brain that cause addiction, to make us eat more food, as they learn how to create cravings for certain products.

Speaker 1:

This is a picture of a taste innovation hub that was being opened, and this is basically a giant scientific lab where they take foods and they manipulate how much fat, sugar and salt they have to see what makes people crave and eat more. And there's even enough scientific research on this that we've actually figured it out, and it's called the bliss point, and I'm going to read you what's on the screen here. The bliss point is the amount of an ingredient, such as salt, sugar or fat, which optimizes deliciousness. In other words, they are actually engineering the food to maximize how much dopamine it releases so that we crave it, we eat it and they make money. And what I'm so amazed about is the industry doesn't even hide it. What is the motto of Lay's? It's bet you can't eat just one? They are not even hiding the fact that they're trying to induce compulsive use of their product. But let's think about this right. What is addiction, cravings, consequences and compulsive use? The food industry is actually inducing food cravings in us and leading us to compulsive use. The industry does not hide that. They're trying to make us eat as much as possible. There's more to the story.

Speaker 1:

Coming back to this book, the Way we Eat Now, our brains are wired for us to live several hundred to several thousand years ago. In other words, our brains can't adapt to how fast our world changes. We are wired to basically still be hunter-gatherers. Food is scarce and things are different. If any of you are hungry, right now you can DoorDash on your phone and get whatever you want. There's so much more variety. Right In 1600, if you wanted Thai food, you had to go to Thailand and that was hard. Now, I mean, doordash has its own little section for Thai food and because of the food industry, there is so much more food available. We're constantly snacking and again our hunter-gatherer brains. We don't have smoothies, or coffee or tea or soft drinks. We only recognize one liquid and that is water. So when you drink a Coca-Cola, your brain does not recognize that it has calories. It thinks it's water. That's why liquids really don't fill us up and unfortunately, the beverage industry is constantly giving us snacks disguised as liquids, which has been a major contributor to obesity in America. The other part of it is this whole engineering food to make us eat more is not good for us. So this is another podcast from npr about ultra processed food.

Speaker 1:

Ultra processed foods are basically things that are manipulated and engineered out of their native form. So think of, like Doritos, those corn chips. You can't see a corn kernel when you open a bag. They grind down the corn, they are able to extract the starchy inside of the corn kernel and then they use a mold to make it look like a chip. There's no corn in a recognizable form in that chip.

Speaker 1:

Ultra-processed food are meant for profit. They have colors to make them exciting, they have sugar, fat and salt to make us want to eat them, and they make up over half of the average American's diet. Unfortunately, they are really not good for us. They increase the risk of cancer, increase the risk of depression, increase the risk of depression, anxiety, diabetes. Through all of those, they increase the risk of premature death. And don't forget, they are engineered to make us eat more. So for someone like me, this is horrible, right? My brain naturally releases more pleasure chemicals when I eat food and the industry is making that response even bigger by ultra-processing these foods into being as pleasurable as possible. So we've talked a little bit about the fact that food makes us release dopamine and other pleasure chemicals in the brain. Some people like me release more than the average person dopamine and other pleasure chemicals in the brain. Some people like me release more than the average person. We've talked about how the food industry engineers food to make it as addictive as possible.

Speaker 1:

Now let's talk about the actual conditions when someone develops a problem with their eating. So an eating disorder is a mental health condition that involves disturbances in eating behaviors, thoughts and emotions related to food, body weight and body image. If you didn't know, eating disorders are not about the food. They are mental health conditions where the food and the eating behaviors are the manifestation of the condition. There's three big eating disorder conditions Anorexia, bulimiaia and binge eating. We'll go through them. So anorexia is basically a distorted body image. It's anxiety about how one looks and how one feels when interacting with others. It's predominantly anxiety. Now, granted, there's behaviors that show up, people restrict their intake, they may engage in excessive exercise, but again, it's all about the anxiety about their own body and appearance. If anyone's heard of body dysmorphia we're going to talk about that in just a sec. That goes hand-in-hand with an eating disorder like anorexia nervosa. Body dysmorphia is basically an anxiety condition where people are not able to see their bodies objectively. Treatment for anorexia nervosa actually can be really complicated because if people are really starved for calories, it's very difficult to introduce nutrition in them again because the kidney doesn't know how to handle all of the electrolytes. Now that the body's getting nutrition again and we're going to talk more about treatment in just a little bit I apologize if this is triggering for anyone, but this was a young woman who wrote about her story with anorexia.

Speaker 1:

She actually wrote about it in a British newspaper. This is an example of body dysmorphia. This young woman is clearly very underweight and she described in this article that when she would see herself in the mirror, all she saw was more weight to lose. That is an example of the thought patterns that happen in anorexia and along with body dysmorphia. You can see, on the right, she got some help and she's been able to gain some weight back. Right, she got some help and she's been able to gain some weight back.

Speaker 1:

Okay, the next one is bulimia. This one has some of the same pathways as addiction because there's binging. So bulimia involves binging, and then patients try to make up or correct for their binging by either somehow getting the food out of them whether it be inducing, vomiting or using laxatives or they'll do something like not eat for a period of time or intensely exercise to make up for the binging. And binge eating is very similar to addiction and I didn't actually know this when I was going through it.

Speaker 1:

One of my friends he had a heroin addiction and was in recovery. He and I were just hanging out one time and he's like Grover, I'm sure you must have dealt with an addiction at some point in your life. You're just like, too open-minded to this stuff. And I was like, no, no, I just had my eating disorder. That was it. And he was like, well, what was it like? And I was like, well, I'd get a craving for chocolate or something sweet and I'd get all restless and I'd try to distract myself and then I could figure out in the house, in my brain, where the chocolate was and I knew it was there and I kept having these thoughts of getting up and going to eat it. But I kept trying to sit on my hands and I kept trying to like, distract myself and I kept trying to do something else and then I just I just couldn't resist anymore and I would go to where the candy was in the house and then I would consume all of it. He's like dude, that's totally like craving heroin, and I didn't know at the time.

Speaker 1:

And yes, binge eating is very similar in the brain chemistry to addiction to drugs and alcohol. The brain wants dopamine, it knows what substance will give it to it and so it starts craving until the person indulges. And I lived it for a lot of years. I would get these really weird food cravings and when the binge starts it's all pleasure, it's all intense feelings of pleasure, it's the sweetness, and then the guilt and the shame and the fear would come in. And the way I would deal with it is I would force myself to vomit and then go for a run. And, yeah, I would not wish an eating disorder on my worst enemy.

Speaker 1:

My biggest problem was bulimia. I actually have damaged my esophagus from all the vomiting. The last one is binge eating disorder, and this is like bulimia without the purging. So this is where somebody will binge on usually intensely sweet, salty or savory foods and then they basically indulge. It's almost like somebody who has a history of alcohol addiction giving into their alcohol cravings, except the cravings are for food. People will eat a large amount and then they'll try to suppress their cravingss again, deal with the shame and guilt and the feeling out of control and and then they'll often do it again, unfortunately.

Speaker 1:

Okay, if you think someone around you has a problem with their eating whether it be binge eating you think they're addicted to something. A lot of times it's not about the food. So the reason I developed my eating disorder is I've had a lot of times it's not about the food. So the reason I developed my eating disorder is I've had a lot of anxiety growing up. I struggled with some body dysmorphia myself and then my dad got diagnosed with terminal cancer and my anxiety went off the charts and I wanted to control something and that's where the control came was trying to control my eating. And for me, when I eat sweet foods, my brain releases dopamine and me, when I eat sweet foods, my brain releases dopamine and those pleasure chemicals like endorphins. It's almost like a downer. It's very soothing until you realize you've binge eaten. But I had to figure out my mental health before I was actually able to really correct my behaviors. So if someone's underweight and they have anorexia, don't tell them to eat. That doesn't help Just as much as walking by somebody who's in relapse and being like dude you should stop using. Be supportive, let them know you care, help them get resources if they need them.

Speaker 1:

You can really think of a lot of these eating disorders as very similar to addiction. We all know dual diagnosis. It's usually some sort of food-related behavior along with a mental health condition. Okay, how do we actually treat disordered eating, including binge eating? And take a look at this list. It's very similar to the menu that we have to treat addiction there's therapy, there's medications, there's support groups and when it gets really bad, there's residential. Very similar to what we do in treating addiction In terms of the actual specific medications that we use the selective serotonin reuptake inhibitors, the SSRIs we talked about those in our psychiatric medicine lecture are some of the most effective and likely.

Speaker 1:

That's because they help treat various things that contribute to disordered eating Anxiety, depression, obsessive-compulsive disorder, body image issues. Ssris help with all of those. The best way to think of how the SSRIs work is they increase your emotional resilience and actually when I was in college and I hit my rock bottom with my eating disorder, I went to the campus psychiatrist and he put me on Prozac and that was actually my first big step in getting better and I was drastically better even within just a few months of on Prozac. And that was actually my first big step in getting better and I was drastically better even within just a few months of starting Prozac. Now there's also the medicine tapiramate. We've talked about tapiramate, also known as Topamax, when we talk about medications to treat alcohol addiction and stimulant addiction, and the way we think tapiramate works is it makes the reward center of the brain less sensitive, so those intensely pleasurable behaviors of binge eating are not as enjoyable, which is also why we think it helps with alcohol and stimulants. And there's also been some research on using the combination of naltrexone and bupropion, also known as Welbutrin to help reduce behaviors of binge eating as well, and for someone like me, the naltrexone made the food so much less pleasurable. That makes perfect sense. And then bupropion is one of the very few antidepressants that increases dopamine levels, and that's why it's thought to be helpful in some addictive things like stimulant addiction, nicotine addiction and binge eating.

Speaker 1:

Now, no lecture on food would be complete without talking about GLP-1 medications. So GLP-1 is a hormone that is made naturally by the body and we secrete it after we eat a healthy, high-fiber diet. It's basically the intestines signal the brain we're full. Let us digest the food. The problem is in America is that almost all of our food is ultra-processed, and so we don't release a lot of GLP-1 when we eat because the food's so crappy. So if you've heard about these medications Ozempic, wagovi, zepbound, manjaro these medications are artificially telling our brain that we're full despite our crappy diet. I would think we should just eat a more healthful diet.

Speaker 1:

But people love these medicines because it allows them to lose weight without changing the foods that they eat. Now what do they actually do? They increase the feelings of being satiated or full. In our world, in addiction medicine, that fullness extends to other things besides just the food. We see some evidence that people shop less and there's also some emerging evidence that people drink less. So I use these medications in my practice for people who want to stop alcohol. It basically makes the thought of drinking less pleasurable because the brain feels satiated, like it has what it needs. And there's some emerging evidence that we can also use it for things like binge eating disorder. But that's really just in the research stages now.

Speaker 1:

Now the last thing, and I will end on a little bit of a rant here. I found this book called Weight Loss Surgery Does Not Treat Food Addiction when I was preparing this lecture, and that is 100% true. One of my patients has anxiety and depression and his brain is like mine. When he eats food he gets an intense pleasure response and because he eats to soothe himself emotionally, like I did, he has gained weight. And unfortunately he went to his doctor who said you should get weight loss surgery. The surgeon probably did a great job but missed the fact that the binge eating isn't a mechanical issue, it's not the stomach's fault, it's a mental health condition and a predisposition to an exaggerated pleasure response in that person. And so I treated his depression, I treated his anxiety. I put him on naltrexone. He was losing weight and I was so mad that the surgeon operated on him anyways. And I just get really frustrated that the people who are supposed to be the best at helping people lose weight seem to completely misunderstand that binge eating is not a food issue, it's a mental health issue.

Speaker 1:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do. For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives.