Eating-disorders dietitian Marci Evans joins us to discuss the current science on “food addiction” (sometimes called “ultraprocessed food addiction”)—and what’s changed since I first interviewed her about this topic for Food Psych back in 2016. We get into how food addiction is defined and measured (and what that definition leaves out), the overlap between disordered eating and high scores on food-addiction scales, how food-addiction discourse perpetuates weight stigma, the nuances behind the research showing that people’s brain scans are different when eating ultraprocessed vs. minimally processed food, and whether it’s really useful to think about food in terms of addiction. In the paid portion, we talk about practical applications: how Marci would help someone who has addictive-like tendencies or thinks of themselves as being addicted to food, what we can learn from this discussion of “food addiction” to help people have a better relationship with food, and more.
The first half of this episode is available to everyone. To hear the whole thing, become a paid subscriber here.
Marci identifies as a Food and Body Imager Healer® practicing from a weight inclusive and anti-oppression lens. She has dedicated her career to counseling, supervising, and teaching in the field of eating disorders. She is a Certified Eating Disorder Registered Dietitian and Supervisor and certified Intuitive Eating Counselor. In addition to her group private practice, in 2015 Marci launched an online eating disorders training platform for clinicians. In 2016 she joined the Simmons nutrition department to co-develop a specialized eating disorder internship and teach graduate level courses on nutrition counseling for eating disorders. She loves books more than just about anything. Find her at marcird.com.
Resources and References
Christy’s second book, The Wellness Trap: Break Free from Diet Culture, Disinformation, and Dubious Diagnoses and Find Your True Well-Being
Subscribe on Substack for extended interviews and more
Marci’s Food Psych episode from 2016
Scientific references (we unpack and complicate all of these ideas in the episode):
Dennis, K., Barrera, S., Bishop, N., Nguyen, C., & Brewerton, T. D. (2024). Food Addiction Screening, Diagnosis and Treatment: A Protocol for Residential Treatment of Eating Disorders, Substance Use Disorders and Trauma-Related Psychiatric Comorbidity. Nutrients, 16(13), 2019–2019. https://doi.org/10.3390/nu16132019
Gearhardt, A. N., & DiFeliceantonio, A. G. (2022). Highly processed foods can be considered addictive substances based on established scientific criteria. Addiction, 118(4). https://doi.org/10.1111/add.16065
Huang, P.-C., Latner, J. D., Bevan, N., Griffiths, M. D., Chen, J.-S., Huang, C. H., O’Brien, K. S., & Lin, C.-Y. (2024). Internalized weight stigma and psychological distress mediate the association of perceived weight stigma with food addiction among young adults: A cross-sectional study. Journal of Eating Disorders, 12(1). https://doi.org/10.1186/s40337-024-01112-x
Huang, P.-C., Lee, C., Griffiths, M. D., O’Brien, K., Lin, Y.-C., Gan, W. Y., Poon, W. C., Hung, C., Lee, K.-H., & Lin, C. (2022). Sequentially mediated effects of weight-related self-stigma and psychological distress in the association between perceived weight stigma and food addiction among Taiwanese university students: A cross-sectional study. Journal of Eating Disorders, 10(1). https://doi.org/10.1186/s40337-022-00701-y
Schulte, E. M., Chao, A. M., & Allison, K. C. (2021). Advances in the Neurobiology of Food Addiction. Current Behavioral Neuroscience Reports, 8(4), 103–112. https://doi.org/10.1007/s40473-021-00234-9
Wiss, D., & Brewerton, T. (2020). Separating the Signal from the Noise: How Psychiatric Diagnoses Can Help Discern Food Addiction from Dietary Restraint. Nutrients, 12(10), 2937. https://doi.org/10.3390/nu12102937
Marci’s 5-part series on food addiction
Marci’s website
Marci’s online courses
Christy’s online course, Intuitive Eating Fundamentals
Transcript
Disclaimer: The below transcription is primarily rendered by AI, so errors may have occurred. The original audio file is available above.
Christy Harrison: I first interviewed you about food addiction back in 2016, which is like a lifetime ago, for my first podcast, Food Psych. And it was one of the most popular episodes of that podcast. So I wanted to have you back on for an update on the research because a lot has changed, obviously in the last nine years, and I think it's important that we stay up on current evidence, especially because that episode has continued to get shared sometimes. And I think the science is changing so quickly and has evolved so much that we really need to dig into what it's actually saying now.
But before we do that, I want to talk about where you're coming from in relation to this area of study, to introduce you to the Rethinking Wellness listeners, most of whom probably know you, but some of whom may not. Your primary orientation to the food addiction research is through the lens of eating disorders. You're an eating disorder clinician so I'm curious what the strengths and limitations and the unique perspective that you might have on this research coming from that place.
Marci Evans: Sure, that's a great setup. As you mentioned, my background and my area of specialty is eating disorders. And so that's the frame that I read this research through. And it's also the frame that I'm thinking about kind of the clinical implications of the food addiction research. And so for better or worse, I am not able to see really, I think outside of the realm of eating disorder disorders. And I want to name that because the food addiction field doesn't necessarily, from my reading of the research, hold in mind a whole lot the world of eating disorders. It's almost like we're occurring in silos alongside one another, which is really interesting.
So I'm mindful of the fact that the research isn't developed through the lens of thinking about researching and helping folks with eating disorders necessarily. And yet that's the lens that I'm extrapolating and applying the implications of the research as I understand it.
Christy Harrison: Yeah, that makes a lot of sense. And there is so much crossover overlap between so called food addiction, which we'll talk about the nuances of that term and problematic aspects of it, and also that overlapping with eating disorders. And I think it is unfortunate that the two sides are so siloed. But I really appreciate your perspective in bringing in unpacking some of this research for an eating disorder audience.
So to start from the 10,000 foot view, what do you see has changed? What are kind of the major changes in the scientific literature on food addiction since our last interview way back in 2016?
Marci Evans: This is really interesting to me. I was digging into the research really intensely around maybe 2014, 2015, 2016, when you and I had that first conversation. And it was a surprise to me that so many people ended up referring back to that podcast episode and referring back to some of the blog posts that I had written because I didn't necessarily consider myself to be an expert in this field. But it was an area that I was really invested in trying to understand that because it was so relevant for me as an eating disorder provider.
The number of people, you know this, Christy, who come to get help come because they are often feeling so distressed about their relationship with food, things feel unhinged, they feel out of their control, and that's why they often come to an eating disorder provider. I sort of found myself in this position that felt a little bit surprising to me. And to be honest, it felt a little overwhelming and a little bit stressful in terms of kind of kicking up my own perfectionism and my own desire to want to get everything I put out into the world sort of exactly, precise and exactly "right," whatever that means.
And I watched myself over a number of years stepping back a little bit and not really staying super on top of the topic. I make the joke that I am really a one trick pony where I do eating disorders and like, that's my gig. I teach and I supervise and I still work as a clinician. I see individual patients still in my practice, but it's really in the realm of eating disorders. But within eating disorders, I have a ton of interests, things that I'm really passionate about. Body image, embodiment, digestive disorders. And then food addiction sort of ended up being one of them, an interest of mine because I love reading scientific research.
And so I noticed that as some of the conversations were becoming a little bit more challenging within the eating disorders profession as it related to food addiction and that things were evolving in the food addiction space, I took a little bit of a hiatus, but was noticing that people were continuing to point to material that I had put out and I started to feel some responsibility. Things have evolved. I haven't really provided much of an update or provided a resource that might be a bit more of an update for clinicians to look to.
And it just so happens that I am right now in the process of co-authoring a textbook and that was the kick that I needed to really sit down and spend actually was, was several months trying my best to wrap my head around the research that's been published over the past few years. So that was a long winded setup but I just wanted to share with a little bit of transparency around my own process of the fact that I try really hard to engage really thoughtfully and openly and critically and try really hard to engage with material that might even be sometimes where I might have my own defensiveness kick up around things that I feel really strongly about and things that I've observed in my clinical practice.
And so I also am working really hard to lean into discomfort, lean into those sort of important conversations that might feel a little tricky. But it was actually really interesting to spend so much time delving into the research. And I think I have at least a handful of points that might be helpful for listeners and getting a sense of what has shifted over the past almost a decade .
Christy Harrison: Wild.
Marci Evans: That feels impossible, but I guess it's true. So I'll just share some the changes that I've observed. So one is a shift in terminology, right? So the research that I was reading from a decade ago, 15 years ago, talked about food addiction and sometimes you'd see the term sugar addiction. But one of the big critiques that I had at the time was this total lack of specificity. It's like, well, what are we talking about? What food, what are people supposedly addicted to? And when we're talking about sugar, are we talking about table sugar? Are we talking about refined, mostly carbohydrate based products?
And, and so there was a real lack of specificity when we were looking at particularly research that was done on humans as opposed to rodents. And so there's been this shift over the past couple of years where there's been a specificity around what's being called ultra-processed food addiction. And that moves us to a bit more specificity where we're looking at these highly processed foods, commercially made foods, where we're looking at typically some sort of combination of carbohydrates and fat that are designed to be really pleasurable and highly palatable.
And often folks are pointing to this classification, which I'm sure you're familiar with, the NOVA classification of foods, which is interesting, although I would say still maybe not as much specificity as folks might think. You think like, oh, it's a NOVA 4. That sounds very scientific, perhaps, but it's this umbrella category that has a huge number of foods and there isn't total agreement in terms of where a certain food might fit. And so some people might classify bread that's maybe made in an industrial kitchen as a group 4. Other people's might say, well, if you look at the ingredient list, it's really a group 3. It's the kind of conversation that I actually quickly become pretty disinterested in. I'm not sure exactly what we're talking about.
Christy Harrison: And it's changed over the years too, right? The people who develop the NOVA classification system have moved things around and other researchers have moved things around or made arguments for one type of food actually being in a different category. Then there's things like commercially produced bread is a four, but like homemade or bakery bread is a category three or something like that. And it's like, okay, what are the actual differences then between these foods?
Marci Evans: Yeah, right. If this is supposedly, and we'll get into this, an ingredient or a process that's creating an addiction, what are we really talking about here? The more I dove into it, I was like, oh, this is maybe not quite as clear as I had originally thought. The other piece, and I think we'll probably get more into this, is that there is some compelling data showing there's a specific response to these ultra-processed foods that are happening in these brain imaging studies that we're not seeing in minimally processed foods, but we don't yet have a causal link between which foods are addictive. This is pretty important. That speaks to this other area that I see as sort of this evolution in the research in that a decade ago there really wasn't consensus around what type of an addiction are we talking about? Are we talking about a process addiction?
So you can think of gambling, that would be considered a process addiction addiction, or are we talking about a substance addiction? Like we might think about alcohol or nicotine or cocaine. And with this framing of the ultra-processed food addiction is really resting on demonstrating evidence that we are talking about a substance based addiction, not a process based addiction. So getting clarity around, well, what substance is it? If we're saying it's a substance, what substance is it? Is it the substance itself? Is it the processing of the substances? So there's a lot in there that I feel pretty curious about and that I haven't been able to kind of get the clarity around it that I'm hoping for. So there's a lot of disagreement and lack of consensus when you start getting really into the nitty gritty details.
Christy Harrison: Right and I think from the lay press and general public perspective, it sort of seems like, oh, there's all this science on ultra-processed foods and even some of the food addiction people will be like, there's so much research, there's a thousand studies now done on this, this is not new science or whatever. But in the grand scheme of things, that is still actually very new science. And there's still a lot of debate among researchers about what we're really talking about here. And like you said, that clarity that you might be looking for about what exactly is it? How do we define what is so "bad" about ultra-processed foods? That is a slippery concept and nobody has really pinned it down. Is it certain ingredients? Is it some sort of process, processing? Nobody knows and it's not a cut and dry scenario. It's certainly not a causal link the way that it's made out to be in the general public.
Marci Evans: Right. There are lots of continued and evolving questions that remain and some pretty fundamental big questions, which if you get into the research and we're very happy to provide you with some of the citations that I'm referencing and informed by today, the researchers themselves say that really plainly, really clearly. I think one of the things that I've appreciated in reading some of the newer research is that things that I was really grappling with or critiquing a decade ago are in some of the research, it's being responded to. I was like, okay, I appreciate that. It sort of helps me drop some of my own defensiveness to allow myself to be a little bit more critically engaged in the scientific process and sort of allowing myself to, I think, be a little bit more open and curious about what is here and how do I understand that and what's not here, what remains to be seen. It's been an interesting, interesting process for me as well.
And there's been evolution, of course, in this area where there's been some mapping done, where the neuroimaging imaging research is mapping onto the Yale Food Addiction Scale diagnosis. So someone might take the food addiction scale and receive a "diagnosis" of a food addiction. And they're like, what is also happening in the brain imaging? And it's like, oh, there's some mirroring there that matches up what one would see. There is, I think, still quite small but growing body of neuroimaging research that showing some structural similarities of ultra-processed foods that is comparable to what we would see with someone with a substance use disorder.
There were some early FMRI studies and of course, and I think we'll probably get into this a bit, there was the Yale Food Addiction Scale that came on the scene. I don't have the date in terms of when that was first published, which is really painting a subjective experience picture. So people are able to look at these questions and get a sense of what is their experience, whereas the neuroimaging research is looking at the actual images of brains and what's happening when people are thinking about or exposed to different types of food.
And so what these researchers are looking at are similar common neural substrates, structural changes to the brain, shared mechanisms and changes in what's called functional connectivity. And the functional connectivity, meaning these different regions of the brain that are in communication with one another and how are they in communication with one another?
And also what they're looking for, as best as I understand, is they're not just looking for in the moment, what are we seeing in the brain scans, which was a bit of a learning curve for me, because when I was critiquing early on and you see this critique quite a bit, which is, well, yeah, those reward centers of the brain do light up, just like when we're holding a baby or listening to music. Any type of activity that would be pleasurable, those pleasure centers light up brain.
And what's helped me to learn the difference is that we're trying to understand, but are there long term changes to connectivity and function as a result of long term exposure and consumption of these foods? This is very early stage research. It's my opinion, when you look at the research that's not just looking at brain regions lighting up, but looking at how do you regions of the brain connect and communicate and are there alterations that happen to the brain over time? This is really limited. Very, very, very early stage research. Really only a handful of studies.
So there's this part of me that gets a little antsy where I'm like, wow. Yes. The field of food addiction studies is evolving and the number of studies does continue to grow and the evidence for really being able to tie and point to very specific foods as being addictive, from my vantage point, there is still a lot of scientific research to be done before I feel really convinced that it is either, I guess, a specific food item or how it is processed or a specific food ingredient.
Christy Harrison: Yeah, totally. I really appreciate all that and I want to put a pin in the brain imaging stuff because I think that is super fascinating. But first I want to go back a little bit and zoom into each point, go through the current main points of food addiction research in some detail and unpack them as we go along. So I think it's helpful maybe to start with how food addiction is defined and measured in the research. Like you said, there's been sort of all these different ways of measuring it throughout the years, from rodents to the early use of the Yale Food Addiction Scale. And now it seems like the Yale Food Addiction Scale is kind of the basis of most of this research in humans. Is that correct? Would you say?
Marci Evans: Yes, that is correct. The Yale Food Addiction Scale, particularly, I think the 2.0, which I believe is the newest version, is really considered to be the gold standard. And that is taken into account in terms of these areas of diagnosis. So the way that I think about it is that we've got a person's individual subjective experience, we have their behavioral symptoms. So what are they displaying? What sort of behavior are they displaying with food and then we have these engagement of the brain regions that are related to reward and motivation.
And yet we know that as clinicians that if this is going to be used diagnostically, which I personally have a lot of reservations about. I don't recommend that any provider use the Yale Food Addiction Scale as a standalone way to diagnose a food addiction. But those pieces taken together is my understanding of how researchers are thinking about making a diagnosis. However, as clinicians, of course we don't have access to neuroimaging, we don't have patients in our office.
So we do the Yale Food Addiction Scale and then put them in an FMRI and then we have a confirmed diagnosis, which is why I think the researchers are feeling pretty excited when, at least in the research, they're sort of mapping onto one another. And those folks are feeling pretty validated. The brain imaging is sort of affirming the Yale Food Addiction Scale as this thing that can be reliably utilized. And I've got some concerns about that and we can talk about that. And that's of course through my lens as an eating disorder provider.
Christy Harrison: So let's talk about that. What does the Yale Food Addiction Scale measure and what does it leave out? I'm really curious about this overlap between clinical eating disorders and Yale Food Addiction Scale scores or other measures of food addiction like brain imaging and things like that. Is there any way to tease apart whether someone is showing signs of genuine "food addiction" or an eating disorder?
Marci Evans: That is a great question. So this scale is not at all designed or intended to screen out for an eating disorder, nor does it ask questions related to past or present dietary restriction or dietary restraint, which is of course one of the central reasons that you have eating disorder providers who get pretty fiery in that the early stage rodent based research was really clear that the amplified responses to sugar that we were seeing in those rodents were occurring in the context of dietary deprivation. And so those of us in the eating disorder profession say that's our day to day work. We see people come in and they have this history of deprivation and then feeling chaotic around eating.
And when we work to decrease the deprivation and the restriction, often there is a bit of a parallel and that as the restriction and the restraint and the moralization and judgment around food, as that lessens, the chaotic end of things tends to lessen as well. We think about the bingeing and the chaos and the disconnected eating often happens in response. I often use the analogy of a pendulum.
I was one of many people who'd get pretty worked up about the Yale Food Addiction Scale because I was like, we're seeing people who, yes, absolutely feel "addicted," but we aren't screening out for restriction, what might be a real primary driver. That's why there's an eating disorder dietitian and researcher David Wiss, who published an article along with Timothy Brewerton, who is, I believe a psychologist or an M.D. He specializes in eating disorders, trauma and substance use. And they published an article, I believe it might have been 2020.
Christy Harrison: I'll look it up and put it in the show notes too.
Marci Evans: Perfect. It's essentially encouraging clinicians to utilize multiple tools to thoughtfully discern alongside with clients. Is this kind of "a false positive?" Is this positive on the Yale Food Addiction Scale, or is this person who is really feeling addicted to food, is this a consequence or a remnant of dietary restriction, restraint dieting, or is this due to something else? Perhaps this is someone for whom they don't have a history of dietary restriction, and maybe their challenges with food started out with binging, and that restriction really isn't part of the profile. And the case that they make is that when you go through a number of processes to understand the full picture of what might be happening for a person, there's a way to kind of parse out what might be a "true addiction" from what we might think of as looking like an addiction, but as perhaps something else.
I think that is an interesting idea. I don't know if we're looking at the behavioral presentation and we're looking at the subjective experience, and we're also looking at the neuroimaging, and we're collectively seeing the same things on the surface, what makes one an addiction and one not an addiction, and why I tend to be less drawn towards an addiction framework and more towards something is happening here. What is happening here? There is a something. And how do we understand what that something is? Do we call it addiction? Might it be something else? Is it amplified salience in response to food?
Christy Harrison: Which can result from restriction, right? Not just the food itself, but that can be the result of restriction.
Marci Evans: It can be the result of a few different things. It can be the result of restriction, malnutrition, perhaps it's the result of the actual food ingredients. Proponents of the ultra-processed food addiction would say it's the actual ingredients. And I know we'll be spending some time on this and brings us back to the neuroimaging conversation, which is we can see a "what" when we're looking at neuroimaging. We can see that something is happening, but we can't necessarily see why it's happening.
So there is a "there" there. Is it the actual ingredients? Because again, one might say, well, we see it with the processed foods, we don't see it with the minimally processed foods. But you and I both know there are moral attachments to these foods, and there are generational legacies, and there are histories, and there is sociocultural messaging, and there is culture. And this is what I'm really interested in. There's a way that we can't strip the ingredients from all that we bring with us. That my history with dried lentils is different than my history with pizza. For me, pizza means, from the time I was little, Friday night, the work week is done, birthday parties. dried lentils I didn't eat growing up. That's not something that I have a lot of history with.
And so that's something I've been really thinking a lot about, is not wanting to dismiss that there's something here. People do have these powerful relationships with food. People respond to Cheetos differently than they respond to broccoli. That's real and that's true. And how can we understand that in all of the complex layers? That's one of the critiques that's not unique to me. Critiques that have been made by many people when it comes to neuroimaging research, is that it is devoid of social meaning and context.
Christy Harrison: Well, yeah and thinking about that in terms of something you said earlier, where these researchers are saying there's a way to tease out perhaps disordered eating or the effects of dieting and chronically restrained eating, sort of making it look like somebody has an addictive relationship with food, when actually it's sort of a result of the restraint versus somebody who didn't have restraint first and they started binging first. And so dieting just isn't part of the picture. I would really question that, too, because I think thinking about the context, again, that we all live in, yes, there probably are some people, I would say probably rare people, in my experience, who have no dieting anywhere in the picture, and it's only binging.
But I think just from what I have seen and what it seems in some of the literature, the restraint often is part of the picture, even if it doesn't come into play first. Because I've known people who were like children when they started turning to food for comfort, and it was a coping mechanism for trauma or something that was going on in their life that they didn't have the language or the tools to cope with otherwise. And so they turned to food and found that it had this soothing effect and did it more, and it became kind of a habit. But then that was often stigmatized. Often weight gain happened, and that was stigmatized, and the person was told to lose weight or shamed for their eating behaviors because it was seen as something that would lead to weight gain or make them unhealthy in some way.
There's all this baggage on perceived overeating or eating certain kinds of foods in our culture that I think it's impossible to really escape and so even if the binging or the eating in what feels like an addictive way preceded the dieting, dieting often becomes part of the picture or restrictive eating, or even just shame about the eating becomes part of the picture for people at some point. And so how do you completely divorce that and say, well, this is an addiction versus this is disordered eating driven by dieting? Oftentimes it's very muddy.
Marci Evans: Absolutely. I think that what we experience in our offices with individuals is just an unbelievable amount of nuance and layers and getting curious about all of those details. And that can, I think, a lot of times unintentionally get erased or can be minimized when we try to put frameworks around these concepts and tried to put steps and things to it. This is really highly individual and there is a lot in there that gets wrapped up into what is considered to be normal and not even noteworthy in our culture.
Christy Harrison: Yeah, it's not even something to be controlled for in the scientific research because nobody thinks of it as anything other than normal.
Marci Evans: Right. This is the way things are.
Christy Harrison: Right. So I'm curious then, with that in mind, how do or do food addiction researchers really control for not just clinical eating disorders, but also subclinical disordered eating or anything kind of on the dieting spectrum? Because there is some researchers who argue that there are areas of non-overlap between the Yale Food Addiction Scale and eating disorder scales, the little slice of the Venn diagram that we're talking about as true food addiction or something. But is it also possible that those areas of non overlap could be something else? Subclinical disordered eating, chronic dieting, diet mentality, that sort of thing?
Marci Evans: Right. Yeah, it's an interesting question. My understanding, as I've engaged in the literature, is that many food addiction researchers don't contend as much as I would like with clinical eating disorders. And there are some researchers who are looking at, is this a food addiction by itself? So we're doing these assessments. We're using the Yale Food Addiction Scale. Not sure exactly what's utilized in the research. I would have to look at the research specifically to see what they're utilizing to screen or assess for an eating disorder. Is it an eating disorder? Is it both?
So there is research that shows, nope, this is just a food addiction. This person just meets criteria for food addiction. This person meets just criteria for an eating disorder. Although I'm going to come back to that. And then there are the individuals who meet criteria for both and what has some eating disorder professionals who also are in the substance use disorder space, really pay attention to this group, because there is research that shows, shows individuals who sort of score positively for both are having worse outcomes in eating disorders treatment and they're having more severe symptoms.
So this does tell us this is a subset of individuals for whom their challenges that are showing up as food symptoms are more severe. And when we look at the clinical picture and, not always, but there tends to be some shared vulnerabilities in terms of histories of trauma, exposure to early childhood adversity. And we're looking at individuals who maybe have PTSD, individuals who maybe have differences in neurological processing, maybe they have a diagnosis of ADHD. So there is something even more notable, even more striking for these individuals who meet criteria for both.
Where this gets a little bit sticky for me is that when we look at diagnosing with the Yale Food Addiction Scale, which I, as I mentioned, have some pretty big concerns about. One, we should mention, ultra-processed food addiction is not something that is actually yet recognized as a formal addiction. It's proposed, but it's not. There isn't agreed upon like in the DSM, like we agree that this is an entity. So the diagnosis is, to my mind, in quotes.
But when we are applying that diagnosis to people who don't have eating disorders, the prevalence rates for the general population in the United States is somewhere around 14 to 15%, which is not far off from other substance use addictions or disorders. But in the eating disorder population, we get prevalence rates that are as high as 97%. So that has me concerned that if clinicians, if they're going to be using this tool and they don't have the training and the skill and the awareness to be assessing and screening for an eating disorder, the likelihood of, you say you are feeling this way, this is your experience and that's real and true and now we have a tool to diagnose it.
And if the primary intervention is, well, it's an ultra-processed food addiction so the way to treat it is to get rid of the ultra-processed foods, that has me as an eating disorder provider, feeling pretty worried. That's where I worry that the application is outpacing how we're understanding this research and because we live in a culture that is really eager to have reasons and proof for food restriction, it's not a hard sell. It's not for a lot of people.
Christy Harrison: For anyone who's not in the eating disorders field and knows why that would be a bad thing to tell someone they have an ultra-processed food addiction versus an eating disorder, the treatments are totally different and the proposed treatment for the proposed diagnosis of ultra-processed food addiction is ultra processed food avoidance. Versus with an eating disorder where there's a restrictive component driving the feelings of addiction, the treatment involves a lot of different things, but among them, making peace with food and trying to not have as many food rules and not restrict and deprive oneself of those particular foods that one feels triggered by and that can look a number of different ways and be approached in a nuanced way. It's not all or nothing.
But I think ultimately the goal is abundance and openness to different kinds of foods and not this sense of rigidity. Because I know there are some people listening who are not really from the eating disorder world so I want to kind of make sure that we highlight that as well.
Marci Evans: Not at all. It was great. It's an important context and I think it speaks to the fact that they're listening to a person, me, who has a particular perspective. I have been writing about this topic in my newsletters, and I'm really trying to encourage people, particularly clinicians as they are my primary audience that I'm speaking to, is to be open to how I'm sharing this information and I hope that it inspires them to critically engage with the material on their own terms. This is hopefully giving them a little bit of an introductory into this topic and that they're, of course, going to ask their own sets of questions and have their own lenses based on the individuals that they work with and what they've seen in the work that they've done with their clients.
Christy Harrison: Absolutely. I want to talk a little more about some of the issues with the Yale Food Addiction Scale and particularly internalized weight stigma. There is some research showing that that correlates with Yale Food Addiction scores. Can you talk a little bit about that?
Marci Evans: This was stunning to me when I was stumbled upon this research, because I actually didn't know it. There have been series of studies, and again, not dozens, but a handful of studies done by a few different researchers where it's a correlation, just like you said, and that weight stigma and internalized weight stigma, as well as the fear of experiencing weight stigma, worsens the experience or feeling of having a food addiction or addictive-like eating.
So there is this parallel, that the more someone has internalized weight stigma or is feeling fearful of being exposed to weight stigma, correlates with a felt sense of addictive-like eating. And I mean, this is just incredibly important to me as somebody who feels very strongly about fat positivity, body liberation, weight inclusivity, that again, it's a correlation, it's not causal. I don't want to make the faulty jumps that I criticize the weight loss research for, but I'm like, wow, I don't want to get too lost in pointing to the food.
And I feel like this is so much of my career, that we see the food as an entry point, but we don't want to just stay at the food. There is something else happening for somebody who has experienced the trauma of weight stigma. I would be very curious about parsing that out and learning more about their histories with dieting, their histories with dietary restriction. Individuals who live in larger bodies are going to be more at risk of being pressured by other people to "fix their bodies."
That's my own deducing there that we've got individuals who are dealing with weight stigma. They are dealing with the stigmatization and the stress of the stigmatization and then are at risk of their being a pointing to, well, you can fix this if you could fix your food and how much you're eating. And then it becomes a personal willpower issue or a moralistic issue around what they are eating. So there's, I think, a lot there to understand and unpack.
Christy Harrison: Yeah. And related to that, you have said that food addiction research and general food addiction discourse contains a lot of weight stigma and can perpetuate harm for higher weight people. Can you talk a little bit about how that weight stigma is sort of woven into the research and the way that people talk about food addiction?
Marci Evans: Oh my gosh, it is pretty painful to read some of the research. I don't know if this is about getting funding, that if you're funding higher weight studies and how to get people to lose weight that your studies are funded, I'm not sure. But the majority of it is wrapped up in treating weight and seeing high weight as pathological. And there is this case that many researchers are trying to make that it's the food addiction that's driving the high weight and that if we can treat the food addiction, then we can treat the weight, which is all sorts of problematic.
And that has actually been critiqued by some food addiction researchers who point out that food addiction, at least diagnosed by the Yale Food Addiction Scale, actually occurs across the weight spectrum. It's not unique to individuals in larger bodies. And that weight, we know, is incredibly complex. There are so many factors that determine where a person's body size is and how it changes over time. So to be pointing to food addiction is really not useful. But I'm a clinician, I'm not a researcher, but I am a clinician who reads a lot of the research. I think about the impact I have witnessed, particularly in clients in larger bodies who have a very long history of being put on diets, being sent to food addiction based communities that were incredibly harmful and actually perpetuated and lengthened their eating disorder.
So there is a lack of attention to, by not all, but most food addiction researchers, a lack of concern for, and certainly no amends attempted to be made by the harms that have been caused, of course, unintentionally. I don't think any of it was malicious, but that have been caused for many people over decades. This language and this framing has been for some people, I'm not going to say, of course, for all people, for the folks that I work with, they come many with these histories of harm.
And one of the things that I will point out is that there are a very few number of people who are eating disorder specialists and who work within the addictions field and are really putting forth, I think, some good faith efforts at trying to repair some of these harms, to not repeat and also to think much more expansively, much more flexibly and much more creatively around what are the multiple tools that we pull in to support people who have an eating disorder and who, according to their framing, also have an ultra-processed food addiction. I don't want to paint with too broad a brushstroke. I think that there are pockets of nuance. But on the whole, what I have read is very aligned with the medicalization of body size and the framing that of course, a larger body is a sick body and a body to be fixed.
Christy Harrison: Yeah, that is well said. Thank you. Let's dig in a little bit more to the brain imaging research. I'm curious what you make of these brain scans and the research showing that they're different when people are eating ultra-processed food versus minimally processed food. We talked about that a little bit and the missing context. But I'd love to hear more about what is missing from that discourse and the jump from, well, it's brain imaging scan, so that has to show that it's causal or the brain imaging scans line up with the Yale Food Addiction Scale and therefore that proves the existence or the validity of this construct versus the reality of the narrowness of these brain imaging scans and what they can show versus what they can't.
Marci Evans: Yeah and I'll offer this up as somebody who is a dietitian and not a neurobiologist. So we have these researchers who are human and who bring their lived experiences and their biases and the sociocultural norms and their training. All of that they bring into the design of the research the questions that they're even asking and then the meaning making of what this is telling us. So these theories are shaped by their own experience, their perspectives, their assumptions, their biases. Just as mine are as well. I am just as flawed of a human. I totally own that.
And so I just chuff to believe that if I was to look at neuroimaging of my clients and they're in one moment eating a salad or something and the next moment they're eating french fries, that it's telling me more than just what ingredients and what went into making that salad and what went into making those french fries that I'm learning something about their own embodied lived experiences that they're carrying. The relationship to food is just layered with all of our sociocultural, familial, spiritual, generational food legacies and that is going to be a part that informs what lights up.
Not to mention our brains have been designed and they've evolved over millennia brilliantly to respond stronger, that there's increased sensitive salience and drive for foods that are energy dense, that was highly palatable. That's the language used in the research, "highly palatable food." We're driven towards it.
And so sure, I guess it doesn't seem like a stretch then that a food that is showing something on that neuroimaging for more highly processed foods is going to be different from minimally processed foods. That's the design. Right now, I am not convinced that it's revealing an addiction. And that's for a lot of reasons. A little of it has to do with the research, but most of it does have to do with my experience working with hundreds of people over a decade and a half, which is when they get, and we know a lot of people, most people don't actually have access to this kind of treatment. But when individuals get really good eating disorders care and opportunity for multi-dimensional healing, over time, these feelings of food addiction don't seem to endure.
And that is not to say that that is everybody's experience. And I want to be really careful about that because the last thing I want to do is alienate or minimize the people for whom they have a different experience. And that's real and true for them and perhaps part of why this theory feels resonant for some people. But my experience is that as people get nourished and as they have access to treatment, and I'm not just talking about getting re-fed, that people don't finish eating disorders treatment and getting exposed to these "addictive" foods, feeling more addicted.
Christy Harrison: And you would think that it would be the opposite if it was genuinely something in the food that was addictive.
Marci Evans: That would be my understanding and there might be a listener who can provide me some clarity on that. I would be really interested in seeing if we were to deliver the Yale Food Addiction Scale, let's just even say residential treatment, sort of before residential treatment or after residential treatment, or a bit of a before and after. In my experience, I don't see people who are able to access treatment, finishing treatment, more dysregulated, more compulsive, feeling more unwell with food.
And I don't want to dismiss the fact that there is that small number of people captured in the research who have this, often, highly complex picture, for whom eating disorders treatment is sorely lacking and they are not feeling like the treatment is actually attending to and feeling helpful for their experience.
Christy Harrison: I absolutely want to co-sign that because I have known people for whom eating disorders were decades long or lifelong struggle even, in and out of treatment, and that something in their experience and their picture just wasn't being served by traditional eating disorders treatment. But that's not everyone, right? That's a subset of people. And I agree that for the most part, I see people going through treatment and becoming less, "addicted" or feeling less addicted to food, including myself.
I didn't go through formal eating disorder treatment, just an outpatient and my own years of recovery and winding path that I had to healing my relationship with food many decades ago now, it was very true that I felt addicted to food and especially certain kinds of foods that we would call ultra-processed now. Like carbs, at the time it was the low carb moment. And so I was really focusing on the fact that they were carbs. But anything sort of sweet or salty, carby, starchy was something I felt like I couldn't have in my house and couldn't let pass my lips, otherwise I'd finish the whole box or whatever.
And now that is just not my reality. I have these foods all the time. I have them in amounts that I don't feel out of control with them. I can have them and put them down. I can go about my day. And not that that's a badge of honor to have something sitting in my pantry because I'll eat it when I want it but I personally have this very real experience of having felt so addicted to these foods and then feeling totally at peace with them through the course of learning to be at peace with them, learning to be exposed to them and the salience of them decreased over time. I also want to not impose that experience on everyone because I know there are some people for whom that doesn't happen or hasn't happened yet, and it feels like faraway dream and feels like it may never happen.
I also am curious in the research, what you've seen because I think I have seen that in some research, people's Yale Food Addiction Scale scores do go down as they receive eating disorder treatment. Is that correct, or is that limited research?
Marci Evans: It's limited. I wish there was more of that research. I'm really interested. And the studies don't go into the kind of detail I wish they did, but it reflects my experience, so, of course, it makes sense that it's sort of affirming to me because I'm like, oh, this is actually what I've seen with I don't even know how many clients at this point that the experience at the beginning versus the experience at the end, the beginning feels very much like a drug. I have clients who said this feels akin to when I'm doing drugs. When I'm eating ice cream, I feel high, like as if I'm smoking weed. They make these comparisons, and then they go through eating disorders treatment, and somehow that feeling doesn't endure.
So one of the questions that I get curious about is, can addictions disappear? Is it an addiction if it is there in one moment, and then after two years of treatment or whatever, we're not measuring it anymore. There's evidence that healing has occurred. Or is it that the addiction framework is maybe not the best match? Is it that it wouldn't be considered an addiction anymore because neurobiological rewiring and healing has happened? I don't know. I'm really interested in those questions. My gosh, I have so many more questions than answers. But I, of course, was really interested in the research that shows that, at least for some people, after going through eating disorders treatment, this diagnosis no longer fits.
Which for me begs the question, particularly for the eating disorders population, how much utility is there to use this food addiction model, is there utility of using the model for a small subset of people for whom even with treatment or traditional approaches for whom that has been proven to be very unhelpful? Is it worth modifying or reducing their exposure to certain foods? And what are the risks and benefits of legitimizing a food addiction for people with an eating disorder?
I'm really curious about the ways in which there are similarities and overlaps in terms of proposed treatments versus how treatment for a food addiction with an eating disorder, like how would that depart from traditional eating disorders treatment? I'm really interested in terms of my clients experience, right? Does an addiction model reduce shame? Does it amplify shame? Does it increase feelings of empowerment? Does it decrease feelings of empowerment? And I believe so strongly that I can't assign that for anybody. That is going to be the experience of the individual that I'm sitting with. Is there a small subset of individuals with an eating disorder for whom a different kind of approach may give them opportunities for healing that maybe they haven't otherwise been able to access?
There's two papers that are looking at treating a food addiction alongside an eating disorder and how that would look. And they kind of bullet point a lot of the pieces or elements of the treatment. There is a lot of overlap, there's a lot of agreement. And I think the big difference would be in terms of the nutritional protocol, in terms of a harm reduction approach. Are we looking at reducing access to certain types of foods? Would it be reducing those foods within certain settings? Is it eliminating those foods? Is it an abstinence based model?
It's not the exact same picture of the community based approaches that many people have a negative reaction to. It is different in terms of what clinicians are proposing within the eating disorders space. There is also some alignment there, that what they're proposing, of course, is adequate calories, that this isn't a dieting protocol. Adequate micronutrients, a balance of macronutrients from all of the kind of core food groups.
This interesting piece here, the piece that is the most charged that the clinicians feel the strongest about, is are we intentionally reducing the exposure or totally eliminating the exposure to these ultra-processed foods? And I actually think that a lot of eating disorder providers use so much nuance in the ways that they work with their clients. I don't think that most eating disorder providers who believe in moving towards helping clients feel okay around eating foods and feeling flexible and embodied, are saying to their clients, nope, you got to pack your fridge. Nope, you have to fill your grocery cart. You have to be eating these foods.
That might be the experience certainly of people in residential treatment settings where there isn't the kind of autonomy and there is a lot of food exposure. But in terms of outpatient care, I think that most outpatient eating disorder providers are incredibly creative and responsive to their clients and try things on and explore, experiment and listen to and learn from their clients lived experiences.
Christy Harrison: Well, I think that's a great segue into what I want to spend the rest of our time together talking about, which is the practical applications of this and specifically how you would work with someone who has what the food addiction world might call addictive tendencies, or that we might call addiction-like tendencies or whatever, or someone who thinks of themselves as being addicted to food.
In the book, you use a case study to look at how clinicians who treat disordered eating clients can approach working with people who feel out of control with certain ultra-processed foods specifically. And you talk about the importance of nuance in this approach and how a person's relationship with food can change over time as a result of this work. And it's not just open the floodgates. You have to have everything, which, as you say, residential treatment people may feel like that.
Also in my experience, people who are just doing their recovery on their own with help of social media, I think can sometimes feel like that because I think some of the messaging out there about intuitive eating and diet culture recovery and all this stuff is just have all the food all the time, open access completely, and no food is off limits. I think in some of my earlier work, maybe I was not nuanced enough about talking about how that process works. And I think there is value to saying all foods fit and you have unconditional permission to eat and sort of these big statements that then require some unpacking.
I think sometimes people don't go past the headline or the quick meme that doesn't do a lot of the unpacking and so can end up feeling this pressure to have everything all the time, eat all the foods that are sort of tricky for them all the time and have them in their house and all at once, which can contribute in some ways to feeling out of control with those foods if you're not approaching it in a way that feels like safe. For some people, maybe it works. But I think a lot of people I have seen need maybe a little bit more support in that process. So I would love to talk about this case study and how you would work with a client in this nuanced way.
Marci Evans: Sure. I was so hearing what you were saying. It's interesting because I have clients for whom
