Since I announced our new occasional Letters to the Editor feature back in August, we’ve gotten some great letters and comments. Here are a couple I want to share: The first, about “food addiction,” raises some interesting questions about the definition of “addiction” in general. And the second highlights a nuance I missed in my recent article about perimenopause, specifically related to menopause hormone therapy. Both of these letters brought up important points that I thought were worth bringing to a wider audience, and I’ll be curious to hear your thoughts in the comments.
Submit your own letters here for a chance to have them included in an upcoming edition!
Food Addiction
Re: “Food Addiction” + Ultraprocessed Foods + Disordered Eating with Marci Evans
Thank you so much for your recent episode on the topic of food addiction. As a public health researcher specializing in harm reduction for substance use, and also someone who has become passionate about weight-neutral approaches to healthcare via my recovery from an eating disorder, I find this topic extremely interesting and learned a lot from your conversation with Marci.
I find the concept of food addiction very difficult to grapple with, because in comparing it to the traditional conception of drug addiction, I find it to be both similar in ways and different in others. Obviously, sugar/UPFs/etc. are not producing the same level of chemical reward responses as fentanyl/nicotine/etc. Also, people need food to survive, unlike alcohol, for instance (with the exception of those who require medically managed withdrawal).
However, I find the concept of addiction in and of itself to be fraught because, in my opinion, it often has to do more with the social circumstances around substance use (as well as trauma, genetics, epigenetics, and more) than the substance itself. I think this is evident in how rates of SUDs differ from country to country—for example, Italy had one of the lowest rates of alcohol use disorder in the world despite the culture’s well-known propensity for wine drinking (Glantz Et al., 2020). And abstinence-based approaches to SUDs have almost as abysmal a success rate as weight loss (Weiss and Rao, 2017), while substitution-based approaches (medications for opioid use disorder, managed alcohol programs, nicotine replacement therapies) are far more effective and often lead to reductions in use over time (Paquette et al., 2022). This signals to me that many of the factors underlying EDs also apply to SUDs: trauma, stress, inequitable healthcare access, the lack of a social safety net, and even scarcity come to mind.
Obviously this is a very complicated issue, and I don’t mean to invalidate any one person’s experiences with either food or substances. However, my hope is to broaden the conversation to highlight some of the nuances around the concept of addiction itself.—Shelby H.
Menopause Hormone Therapy
Re: Think You Might Be in Perimenopause? Don’t Fall for These Wellness Traps.
Hi Christy,
By way of introduction, I want to let you know I am a very big fan of your work and am always learning something new through your podcasts or Substack articles. I am a reproductive psychiatrist, and many of my patients are women going through perimenopause with psychiatric symptoms, so I felt compelled to clarify a few things I feel you did not do justice to in your article on perimenopause and hormone therapy.
I completely agree with the vast majority of what you say (esp re: non-specificity of perimenopause symptoms, and the need to rule out other causes), but I want to specifically highlight where I think you did not dig deep enough into the data: The umbrella article you quote did not differentiate between oral and transdermal estradiol. Oral goes through first-pass metabolism, and transdermal does not, which greatly impacts safety profiles. Transdermal estrogen isn’t just “thought” to be safer than oral, as you state; we have decent evidence indicating it does not increase risk of venous thromboembolism and at standard doses (≤50 μg/day) is not associated with increased stroke risk over baseline/controls. RCTs in perimenopausal women are limited and have not demonstrated statistically significant reductions in hard cardiovascular events, but transdermal estradiol has shown favorable effects on surrogate markers such as lower LDL cholesterol, improved endothelial function, and reduced insulin resistance. Though we don’t have data to support that it improves CVD, what data we do have suggests it at least does not increase those risks the same way that oral estradiol does.
When considering the safety of menopause hormone therapy, formulation, route of delivery, and timing determine safety. The umbrella review does not distinguish amongst these important factors, which is a significant limitation identified by one of the reviewers that was ultimately not addressed in the final publication. There is a much better article, published by the American College of Obstetricians and Gynecologists, that does a better job examining the data and explaining findings.
I would love to see you address this if you have the time and space. I love turning people to your work because I feel the way you think is a good example of how I think about mental health and “wellness” as well. There is already SO much misinformation out there that I discuss in my office daily, and I would hate for a piece you wrote to be part of the information out there that I have to “unteach” my patients.
Best,
Rachel
Thanks to both of those letter writers for their input! Based on Rachel’s feedback, I plan to edit the hormone-therapy section of the perimenopause piece to briefly mention some of that info on oral vs. transdermal estradiol.
I’m hoping to continue publishing occasional Letters to the Editor going forward, so please submit your letters here for a chance to have them included in an upcoming edition! (Fyi, this is separate from our regular Q&A feature, for which you can submit questions here. Letters to the Editor are about sharing *your* perspective, not asking about mine.)
