Abstract
All he does is think about food. . . . When I wake him up in the morning, the first words out of his mouth are, “What’s for breakfast?” And then he’ll be eating breakfast and already asking me for the exact time of his next meal and what it will be. . . . I fear the times we are out and it’s approaching the next time he has been told a meal or snack is coming . . . he becomes so fixated on the time and that that is the time he is supposed to be eating next . . . all he does is think about food constantly.
The literature on food addiction is still emerging, and since food addiction is not a diagnosis in ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) or DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), researchers, clinicians, and laypeople have used this term to describe a broad range of addictive behaviors related to food. Food addiction definitions vary, but it has been described as eating food in larger portions without the ability to reduce the amount even when there are negative consequences.1-4 In addition, food addiction involves a similar biochemical reinforcement pathway as substance addiction including tolerance (needing more to feel satisfied) and withdrawal symptoms with foods that are high fat, high sugar, and/or high salt most commonly involved.1-4 The prevalence of food addiction in youth with obesity has ranged from 4% to 71%.5,6
Similar to substance addiction, food addiction is also associated with a variety of negative behaviors. These include more binge days, more frequent food cravings, and higher eating frequencies. In a group of weight management seeking youth, Meule and colleagues found 38% exhibited food addiction and were more likely to engage in impulsive acts. 7 Youth with symptoms of a food addiction also experienced hunger more frequently than youth who do not have food addiction symptoms. 5 Some researchers have found that those with food addiction are at risk for developing other addictions and/or comorbid emotional and behavioral disorders. 7 This suggests that food addiction is a unique subgroup of the population with pediatric obesity.
Given the potential that food addiction or addictive-like behaviors occur in youth who are obese, the purpose of this brief report is to highlight 3 potential screening tools that can be used by medical providers to identify this unique subgroup of youth, and call for more research in assessment and treatment for this population.
Clinical Assessment of Food Addiction
A review of the literature, as well as the author’s own work in this area, leads to 3 potential tools that could be used by clinicians to assess the phenomena of food addiction in youth presenting for treatment.
Eating Behaviors Questionnaire (EBQ) 8
Normed population: Piloted on 50 children between the ages of 8 and 19, the EBQ was developed within a Pediatric Lipid Center.
Ease of use: The measure consists of 20 questions answered on a 6-point Likert-type scale ranging from never to always.
Basis for questions: The questions are based on DSM-IV substance abuse and dependence criteria. It measures the “3 Cs” of addiction: Compulsive use, Consequences, and attempts to Cut down. Parent and child forms were created with higher scores indicating greater symptoms of food addiction.
Preliminary results: Results of their preliminary evaluation of the EBQ found promising results that this tool could be useful for describing a segment of youth with an addictive eating pattern. Parent and child reported behaviors were similar. On the question, “Do you think you are addicted to food?” 15.2% of youth completing the measure endorsed that they “often,” “usually,” or “always” feel that way.
FOCUS on a Fitter Future Food Addiction Algorithm (Unpublished Tool)
Normed population: Not normed as a measure, but used frequently in the research literature.
Ease of use: The parent screening is 1 yes/no question, while adolescents answer 2 yes/no questions. The questions developed were the following:
Parents: Is your child unable to do age-appropriate activities because he/she would prefer to eat food like sweets, carbs, salty, or fatty foods or sweetened beverages?
Adolescents: Are you unable to do age-appropriate activities because you would prefer to eat food like sweets, carbs, salty, or fatty foods or sweetened beverages?
To feel as good as you used to do you need to eat more of the same foods such as sweets, carbs, salty, or fatty foods or sweetened beverages?
Basis for questions: A subgroup of pediatric psychologists reviewed the literature to develop several screening questions that could be used quickly in a clinic setting to determine if a child needs further evaluation for disordered eating. Endorsement of “yes” to any of the above questions would indicate further assessment.
Preliminary results: While no published results have been obtained from this screening, it has been used by clinicians involved in the FOCUS on a Fitter Future Collaborative successfully
Yale Food Addiction Scale for Children (YFAS-C) 9
Normed population: 75 families from the community ranging from lean to obese.
Ease of use: 25 questions answered on a 5-point Likert-type scale ranging from never to always.
Basis for questions: Adapted from the adult version of the Yale Food Addiction Scale, it was modified for reading age and changes to activities to be more age appropriate. It was then reviewed by a panel of experts for agreement.
Preliminary results: Preliminary work finds the YFAS-C to have adequate validity and consistency.
The 3 measures described above can be easily integrated into the clinical setting to potentially identify youth with maladaptive eating behaviors, specifically food addiction. More research with larger samples is needed to identify the reliability, validity, and relative utility of each. A limitation to all measures is the lack of a widely recognized definition for food addiction, which likely suggests that all 3 measures may be defining the term slightly differently.
Discussion
This brief report highlights the state of the literature with regard to assessing pediatric food addiction. Despite the various definitions of food addiction there is now at least some convergence on symptomatology in 3 tools available for use in clinical care settings. Each of the tools presented can be easily incorporated into practice.
However, more work is needed. Future research is necessary to better describe the construct of food addiction and the etiology underlying this condition. Unlike other abused substances, food cannot be avoided and treatment will be complex. Use of these tools will assist in better identifying prevalence in clinical populations and identify target populations for clinical treatment research that is needed to better understand what treatment approaches and techniques will have the most beneficial impact.
Author Contributions
All authors participated in the conceptualization of the manuscript, a first draft, critically reviewed the final manuscript and approved the final mansucript as submitted.
Footnotes
Acknowledgements
The FOCUS on a Fitter Future algorithm was completed through the author’s participation in FOCUS on a Fitter Future through the Children’s Hospital Association (CHA).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.