Food Addiction: A Barrier for Effective Weight Management for Obese Adolescents

Abstract

Background:

Findings from studies of food addiction in adults suggest those with food addiction are less successful in weight-loss interventions. Little is known about food addiction in obesity treatment-seeking adolescents; therefore, the purpose of this study was to explore the prevalence of food addiction and correlates of food addiction symptoms in obese adolescents entering an outpatient, weight management program.

Methods:

Obese adolescents (n = 26) were administered the Yale Food Addiction Scale for Children (YFAS-C), measures of appetitive responsiveness, and health-related quality of life (HRQOL) before and following a 12-week, outpatient, behavioral weight management program. Descriptive statistics and correlations between YFAS-C symptoms and study variables were performed and further examined with linear regression. Baseline differences were compared between those meeting criteria for food addiction to those who did not (independent t-tests) and pre–postweight management program changes were examined (paired t-tests).

Results:

30.7% met criteria for food addiction and 50% reported ≥3 symptoms. Number of YFAS-C symptoms was correlated with appetitive responsiveness (r = 0.57, p < 0.05) and inversely correlated with all domains of HRQOL (r = 0.47–0.53, p < 0.05). Attrition rate was higher in adolescents with food addiction compared to those without (62.5% vs. 44.4%, p < 0.05).

Conclusions:

Adolescents with food addiction or with a higher number of food addiction symptoms may warrant additional resources to support adherence to and retention with a weight management program. Implementing screening measures for food addiction before enrolling in a weight management program may be an effective strategy to identify adolescents who may benefit from adjunct modalities.

Introduction

The onset of obesity is complex with a variety of causal factors. Genetic predisposition, environmental and social influences, and the food environment have all been implicated in this process.^1,2 Humans, in general, are biologically predisposed to overeating in environments where food resources are abundant.³ The modern food industry has provided ample and accessible, highly refined, and processed foods that are high in sugar, salt, and fat to enhance their affordability, palatability, desirability, and shelf-life.⁴

To some extent, all individuals engage in eating for pleasure; however, it appears that a subset of individuals not only demonstrate an enhanced sensitivity or greater appetitive responsiveness to a food-rich environment but also may develop addictive-like eating behaviors potentially leading to excess weight gain and subsequent obesity.^5,6 The term “food addiction” has been used to describe a cluster of eating behaviors similar to behaviors associated with drug-related addictive disorders.⁷ Although food addiction is not currently recognized as a clinical diagnosis, the central behaviors associated with substance addiction (i.e., craving and withdrawal) are also key factors in disordered or problematic eating and overeating.⁸

In adults, mounting evidence suggests that chronic consumption of certain types of food, in particular highly processed, hyperpalatable foods rich in sugar and fat, activate the mesolimbic reward area in the brain similar to that of drugs of abuse (i.e., alcohol and opioids).^6,9 Obese adults who ingested high-sugar foods exhibited addictive-like behaviors, including withdrawal, craving, and tolerance, that correlated with addictive-like eating behaviors similar to adults with drug or alcohol dependence disorders.⁶ Coupled with an obesogenic food environment, the potential possibility that foods can trigger biologic processes similar to those observed with drug addiction may be significantly contributing to overeating, enhanced preference for- and motivation to consume such foods, and subsequent obesity.¹⁰

Adolescence is a critical period of formative neurodevelopment, whereby the brain can be sculpted in response to the context in which one is exposed.¹¹ In addition, adolescence is also a time during which the presence of obesity and obesity-related complications are more likely to persist into adulthood.¹² Should food addiction follow the same trajectory as substance addiction, adolescents who exhibit addictive-like eating behaviors may be at greater risk for food addiction and obesity that will persist into adulthood, become increasingly difficult to treat using current treatment paradigms, and result in greater morbidity and earlier mortality.^13,14

Preliminary investigations in overweight and obese children revealed eating behaviors consistent with addictive-like eating and food addiction,¹⁵ as well as a portion of these children reporting that they often felt addicted to food.¹⁶ It is estimated that ∼4%–7% of children meet the diagnostic threshold for food addiction and up to 16% of children have three or more symptoms of food addiction consistent with addictive-like eating.^13,17 Ongoing research in this area suggests that food addiction might be a contributor to obesity in children.¹⁸ It is unclear if food addiction is a barrier to success for children enrolled in weight-loss management programs. However, studies in obese adult populations demonstrate that individuals with food addiction and a greater number of food addiction symptoms are less successful when enrolled in traditional weight-loss programs.¹⁹ Thus, a thorough evaluation of the role an addictive process might play in children is both warranted and urgent particularly those referred for weight management.

Findings from a systematic review of weight management interventions support behavior-based programs as effective obesity treatment methods for most children and adolescents.²⁰ Unfortunately, attrition rates in these weight management programs range from 27% to as high as 73%.²¹ Commonly cited contributors to attrition include logistical barriers (i.e., scheduling and transportation), motivation, and parent/child expectations.^22,23 Should food addiction pose an additional barrier, it is plausible that attrition rates would be even greater.

Individuals with substance addiction are more likely to require additional healthcare services and targeted therapy to effectively treat their disease. In the same vein, individuals with food addiction may be better positioned for weight-loss success if resources/support above those traditionally offered in behavioral weight-loss programs were incorporated into their treatment plan. To optimize weight management and appropriate resources, elucidating the incidence of food addiction in adolescents, particularly those seeking weight-loss treatment, is essential.

In adolescents admitted for inpatient, weight-loss treatment, Meule et al.¹⁸ recently observed a prevalence of food addiction of 38%, whereas prevalence was much lower among adults seeking outpatient, obesity treatment. Lent et al.²⁴ and Burmeister et al.¹⁹ reported a food addiction prevalence of 15.2% and 19%, respectively, in adults seeking outpatient, behavioral weight-loss treatment. In addition, prevalence of food addiction in adults determined by meta-analyses was reported to be 19.9%.²⁵

The prevalence of food addiction in adolescents seeking outpatient, behavior-based weight-loss treatment is unknown. Therefore, the purpose of this study was to explore the prevalence of food addiction and correlates of food addiction symptoms among obese adolescents before entering an outpatient, 12-week weight management program. In this study, we expected prevalence of food addiction to be lower than the 38% observed in adolescents admitted for inpatient, obesity treatment,¹⁸ and more in line with the prevalence witnessed in outpatient, treatment-seeking adults.^19,24 Therefore, we hypothesized that the prevalence of food addiction in this study would range from ∼20%–30%.

In addition, we sought to examine appetitive responsiveness and health-related quality of life (HRQOL) as correlates of food addiction. Appetitive responsiveness captures the psychological impact of being controlled by food, independent of consumption, in food-abundant environments.⁵ In a community sample of healthy weight and overweight children, food addiction symptom count was significantly correlated with appetitive responsiveness.¹⁷ HRQOL refers to an individual's physical, social, and emotional well-being.²⁶ There is evidence to support that obese adolescents report lower levels of HRQOL than their healthy weight peers.²⁷ Moreover, an inverse dose relationship has also been observed between HRQOL and body mass index (BMI).²⁸ Taking into account findings from these previous examinations, we hypothesized that adolescents meeting the threshold for food addiction “diagnosis” and/or those with a higher number of food addiction symptoms before beginning the weight management would demonstrate greater appetitive responsiveness and lower HRQOL.

Secondary aims were to explore the relationship between baseline food addiction status and symptom count, and weight and attrition outcomes following participation in the weight management program. Obese adolescents with a higher number of food addiction symptoms and/or those meeting the threshold for food addiction diagnosis may be unable to mitigate their drive to eat related to neurobiological changes that stimulate the drive to eat and enhance the motivation to consume hyperpalatable foods. As a result, behavioral weight management programs aimed at physical activity, healthful eating, and portion control may be less likely to be effective in food-addicted adolescents, resulting in higher levels of attrition and poorer weight-related outcomes. We therefore hypothesized that adolescents diagnosed with food addiction and/or a greater number of food addiction symptoms before entering the program would have poorer weight-related outcomes and greater attrition from the weight management program.

Methods

Participants and Setting

A total of 26 Caucasian adolescents (12 males, 14 females; 12–18 years) were evaluated before and following a 12-week, evidence-based, outpatient behavioral weight management program from 2013 to 2015. Inclusion criteria for the weight management program were as follows: 12–18 years of age, classified as overweight or obese using age- and sex-specific body BMI percentiles Centers for Disease Control and Prevention (CDC).²⁹ Subjects with chronic disease (i.e., diabetes, heart disease, or cancer), taking medications that affected body weight or blood pressure, being treated for severe mental illness (i.e., schizophrenia and bipolar disorder), or taking psychotropic medication were excluded. Medical clearance/approval from the subject's primary care provider was obtained before study participation. The study was approved by the University of Vermont Institutional Review Board. Written assent and consent were obtained from the adolescents and parents before any study procedure.

Procedures

One to 2 weeks before the first weekly meeting of the weight management program, all adolescents participated in a baseline evaluation, which included the assessment of body composition and food addiction. The 12-week, multidisciplinary weight management program consisted of physical activity and nutrition instruction, as well as behavioral instruction derived from social cognitive theory.^30,31 Each adolescent and (at least) one parent were expected to attend each weekly meeting. A similar evaluation was performed 1–2 weeks following the last weekly meeting of the weight management program.

Anthropometrics and Body Composition

For the weight and height measures, each participant wore only one layer of clothing and removed his or her shoes. Weight was measured to the nearest 0.1 kg with an electronically calibrated scale (Seca 869 electronic personal scale, Seca Ltd., Hamburg, Germany) and height measured to the nearest 0.1 centimeter with a transportable stadiometer (Seca 213 Stadiometer, Seca Ltd., Birmingham, United Kingdom). Body mass index was calculated as body weight divided by height squared (kg·m²) and BMI z-scores according the child's age and sex were determined using a pediatric z-score calculator.³² Dual-Energy X-ray Absorptiometry was used to determine percentage of fat, fat body mass, and lean body mass in the adolescents.

Behavioral Measures

Food addiction “diagnosis” and food addiction symptom count were quantified using the Yale Food Addiction Scale for Children (YFAS-C).¹³ The YFAS-C includes two scoring options: a food addiction symptom count (ranging from 0 to 7) and a dichotomous (yes/no) food addiction, clinical impairment diagnosis variable. Participants are allocated a symptom score from zero to seven corresponding with the number of food addiction symptoms endorsed. Consistent with quantification of severity of substance use disorders, a symptom count of ≥3 indicates moderate levels of addictive-like eating.³³ A diagnosis of food addiction can be made if at least three symptoms are reported plus clinically significant impairment or distress. Internal consistency was Kuder-Richardson's α = 0.78.¹³

Appetitive responsiveness was measured using the Children's Power of Food Scale (C-PFS).^34,35 Higher scores demonstrate greater appetitive responsiveness and greater psychological control by the food environment. An aggregate score is available as well as three additional factors when food is (1) available, but not present, (2) present, but not tasted, and (3) present and initially tasted, but not eaten. Higher scores indicate greater appetitive responsiveness. Cronbach's α ranges from 0.61 to 0.89.³⁴

The Pediatric Quality of Life Inventory (PedsQL)³⁶ was employed to determine HRQOL. The PedsQL comprised four multidimensional scales that, including physical, emotional, social, and school functioning, produce three summary scores of psychosocial health, physical health, and a total overall HRQOL score. Higher scores indicate higher levels of HRQOL. Internal consistency for the psychosocial, physical, and total scale score was Cronbach's α = 0.83, 0.80, and 0.88, respectively.³⁶

Statistical Analyses

All statistical procedures were performed in SPSS, version 22.0. To explore our specific aim (prevalence of food addiction and the relationship of food addiction symptoms to study variables), descriptive statistics and Pearson correlation coefficients between YFAS-C symptom count and study variables were computed (Table 1). Differences at baseline between those identified as food addicted and nonfood addicted were assessed with an independent samples t-test, two tailed. A one-way analysis of covariance was performed to examine baseline differences between food addicted and nonfood addicted to control for age. Gender distribution between adolescents meeting criteria for food addiction and those who did not was compared with chi-square tests. Variables significantly correlated with YFAS-C symptom count were further examined with a linear regression. To explore our secondary hypotheses, continuous study variables between those with preweight and postweight management data were compared using paired samples t-test, and change in predichotomous to postdichotomous variables (i.e., individual YFAS-C symptom endorsement) was evaluated by a McNemar test. Significance was set at the 0.05 level for all analytic procedures.

Table 1.

Descriptive Statistics of Study Variables and Correlations with the Number of Food Addiction Symptoms

n = 26	Mean	SD	Range	r
Yale food addiction scale for children (symptom count)	2.35	1.8	0–5	—
Age (years)	14.0	1.9	11.0–18.0	0.45^*
Weight (kg)	89.7	23.1	60.2–157.1	0.14
Body mass index (wt[kg]/ht[m]²)	33.0	6.3	24.3–47.3	0.23
Standardized body mass index (zBMI)	2.10	0.4	1.17–2.94	−0.05
Fat mass (kg)	39.4	12.8	21.4–70.0	0.20
Lean mass (kg)	47.0	10.7	32.4–79.7	0.05
Percent fat (%)	45.0	5.0	36.5–54.7	0.20
Children's power of food scale	2.14	0.8	1.13–4.13	0.57^**
Psychosocial HRQOL	76.0	15.1	50.0–100.0	−0.47^*
Physical HRQOL	75.8	15.2	50.0–100.0	−0.52^**
Total HRQOL	76.0	14.0	53.3–98.9	−0.53^**

p < 0.05;

p < 0.01.

HRQOL, health-related quality of life; SD, standard deviation.

Results

Subject baseline characteristics are provided in Table 1. No significant differences between males and females were observed in any measured variables at baseline, including the number of food addiction symptoms (males = 1.75, females = 2.86, p = 0.11, d = 0.64). Before beginning the weight management program, 8 of the 26 (30.7%) adolescents (3 males, 5 females) met the criteria for food addiction (≥3 symptoms + clinically significant impairment or distress). Thirteen of the 26 adolescents (50%) reported ≥3 food addiction symptoms, indicating moderate levels of addictive-like eating. The number and proportion of adolescents according to each of the seven YFAS-C symptoms along with the clinical thresholds for food addiction are presented in Table 2. The number of YFAS-C symptoms was significantly correlated with appetitive responsiveness (r = 0.57, p < 0.05) and inversely correlated with all domains of HRQOL (r = 0.47–0.53, p < 0.05).

Table 2.

Endorsement Rates of Yale Food Addiction Scale for Children Symptoms and Clinical Thresholds at Baseline (N = 26)

YFAS-C symptoms	Met symptom/threshold, n (%)
Continued use despite problems	14 (53.8)
Loss of control	4 (15.4)
Inability to cut down	14 (53.8)
Large amount of time spent	2 (7.7)
Given up activities	12 (46.2)
Tolerance	8 (30.8)
Withdrawal	7 (26.9)

Clinical thresholds	N (%)
≥3 symptoms	13 (50.0)
Clinically significant impairment or distress	9 (34.6)
Food addiction diagnosis (≥3 symptoms and clinically significant impairment or distress)	8 (30.7)

YFAS-C, Yale Food Addiction Scale for Children.

Baseline variables were compared between those identified as food addicted and nonfood addicted. No significant differences in body composition variables (fat and lean mass, and percent fat) were observed between these two groups; however, those classified as food addicted were significantly older than the nonfood addicted (15.3 ± 2.1 vs. 13.4 ± 1.6, p < 0.05). Significantly lower psychosocial HRQOL (63.3 ± 13.0 vs. 81.7 ± 12.6, p = 0.01) and total HRQOL scores in those classified as food addicted versus nonfood addicted (65.1 ± 9.9 vs. 80.8 ± 13.0, p < 0.01) were observed. Differences in psychosocial and total HRQOL scores between the two groups remained significant after adjusting for age (psychosocial adjusted means 62.2 vs. 82.2, p < 0.01 and total HRQOL 64.6 vs. 81.0, p < 0.05). No significant difference was observed in physical HRQOL between those identified as food addicted and nonfood addicted (68.4 ± 11.5 vs. 79.2 ± 15.8, p = 0.10). To further evaluate the impact of food addiction symptoms on total HRQOL, we performed a regression analysis to identify the unique effects of baseline YFAS-C symptom count, appetitive responsiveness, and percent fat on the outcome variable, HRQOL. In the context of this model, YFAS-C symptom count was the only significant predictor of HRQOL (b = −4.74, p < 0.05), such that an increase in the number of YFAS-C symptoms was associated with lower HRQOL.

Comparison of prestudy–poststudy variables along with endorsement rates preparticipation to postparticipation in the weight management program is reported in Table 3. A total of 13 adolescents (7 males and 6 females) were assessed following the 12-week program with an overall attrition rate of 50%. Attendance with the weight management program was significantly lower in the adolescents identified as food addicted compared to the nonfood addicted (4.5 ± 2.3 vs. 8.0 ± 3.4, p < 0.05), and attrition was significantly higher in those identified as food addicted compared to the adolescents who did not meet criteria for food addiction (62.5% vs. 44.4%, p < 0.05). Of the eight adolescents identified as food addicted at baseline, only three completed the entire 12-week weight management program. Following completion of the program, two of the adolescents no longer met the criteria for food addiction, while one still met the criteria for food addiction (although his symptom score decreased from 4 to 3). In the 13 adolescents overall, symptom counts decreased from pre to post (2.1 vs. 1.0), but this was not statistically significant (p = 0.068).

Table 3.

Study Variables and Endorsement Rates of Food Addiction Symptoms Preparticipation and Postparticipation in the Weight Management Program (N = 13)

	Pre Mean ± SD	Post Mean ± SD
Yale food addiction scale for children (symptom count)	2.08 ± 1.6	1.00 ± 0.9
Weight (kg)	83.1 ± 12.8	83.8 ± 12.3
Body mass index (wt[kg]/ht[m]²)	30.7 ± 4.2	30.4 ± 4.1
Standardized body mass index (zBMI)	2.06 ± 0.4	1.99 ± 0.4^*
Fat mass (kg)	35.6 ± 8.2	35.0 ± 7.8
Lean mass (kg)	44.6 ± 5.3	46.2 ± 5.7^**
Percent fat (%)	43.9 ± 4.3	42.7 ± 4.7^*
Children's power of food scale	2.13 ± 0.8	1.98 ± 0.6
Psychosocial HRQOL	75.0 ± 13.7	74.1 ± 8.3
Physical HRQOL	74.3 ± 15.3	76.9 ± 12.7
Total HRQOL	74.7 ± 13.7	75.1 ± 9.4

YFAS-C food addiction symptoms	n (%)	n (%)
Continued use despite problems	7 (53.8)	5 (38.5)
Loss of control	0	0
Inability to cut down	6 (46.2)	4 (30.8)
Large amount of time spent	1 (7.7)	0
Given up activities	5 (38.5)	2 (15.4)
Tolerance	4 (30.8)	1 (7.7)
Withdrawal	4 (30.8)	1 (7.7)
3≥ symptoms	5 (38.5)	1 (7.7)
Clinically significant impairment or distress	4 (30.8)	2 (15.4)
Food addiction diagnosis (≥3 symptoms and clinically significant impairment or distress)	3 (23.1)	1 (7.7)

p < 0.05

p < 0.01.

Discussion

The primary aim of this study was to explore the prevalence of adolescents meeting the criteria for food addiction before beginning a weight management program. To our knowledge, this is the first investigation of the prevalence of food addiction in adolescents seeking outpatient, behavioral treatment for obesity. In this study, the prevalence of adolescents meeting the criteria for food addiction was 30.7%, well above the 15%–19% range observed in obesity treatment-seeking adults^19,24,37 and closer to the 38% prevalence observed in adolescents during their first 2 weeks of inpatient, weight-loss treatment in a rehabilitation hospital.¹⁸ Notably, the prevalence of food addiction in the adolescents observed in this study (∼31%) was similar to the prevalence reported in obese adults preparing to undergo bariatric surgery (32%).³⁸

The majority of the adolescents (50.5%) reported ≥3 food addiction symptoms indicating moderate levels of addictive-like eating with continued use despite problems and inability to cut down as the most often endorsed symptoms. Comparisons of endorsed symptoms to previous studies were unable to be made as the symptoms vary slightly between the adult YFAS version used in those studies and the YFAS-C used in this study. The number of symptoms endorsed in this study (irrespective of which particular symptoms) was similar to those reported from a meta-analyses of adult studies (2.4 ± 1.8 vs. 2.8 ± 0.4, respectively). When compared to clinical [seeking weight-loss treatment, diagnosed with binge eating disorder (BED), bulimia nervosa, or candidates for bariatric surgery] and nonclinical adults, the mean number of symptoms observed in the adolescents fell between these two samples (4.0 ± 0.5 and 1.7 ± 0.4, respectively).²⁵

It is unknown why we observed a higher prevalence of food addiction in our weight-loss seeking adolescents than previous studies in treatment-seeking adults. In a community sample of children that included both healthy weight and overweight, an increased prevalence of food addiction and number of symptoms was associated with a higher BMI.¹⁷ Therefore, as overweight and obesity in adolescence often persist into adulthood, one may expect a similar or perhaps higher prevalence of food addiction in treatment-seeking adults. Although it has also been proposed and results from this study support that a nonlinear relationship exists between food addiction and BMI within obese samples.³⁹ These findings are again similar to those observed between body mass and food addiction in adolescents admitted for inpatient, obesity treatment¹⁸ as well as adults before beginning a behavioral, weight management program.¹⁹

Our hypothesis that adolescents meeting the criteria for food addiction and/or those with a higher number of food addiction symptoms before beginning the weight management would demonstrate greater appetitive responsiveness and lower HRQOL, was supported. The number of food addiction symptoms was positively correlated with greater appetitive responsiveness. This is in line with findings from a previous examination that also observed a significant association between appetitive responsiveness and symptoms of food addiction in children.¹⁷ It is unclear, however, whether there is a causal direction between these two variables or whether they are working synergistically in the current, obesogenic environment.

Similar to findings from previous examinations between food addiction symptoms and other psychological variables, we observed significant, inverse relationships between food addiction symptoms and HRQOL before the adolescents beginning the weight management program. In both adolescents and adults, food addiction was associated with more symptoms of depression¹⁹ and higher impulsivity.¹⁸ Lower levels across all domains of HRQOL have previously been attributed to weight status and weight severity^28,40; however, we did not find a significant association between body mass and HRQOL.

Notably, we did observe significantly lower psychosocial HRQOL and total HRQOL scores in adolescents meeting the criteria for food addiction than their nonfood-addicted peers, despite no significant differences in body composition between these two groups. This is of significant concern since evidence supports that obese children, as a whole, with poorer HRQOL have unhealthy weight trajectory over time.^41,42 The causal pathway remains unclear: Does poorer HRQOL lead to food addiction or the reverse? Research to further examine the directional effect and how it relates to successful weight management programs is needed as mutual interactions among food addiction, enhanced appetitive responsiveness, excess weight, and HRQOL may likely exist.

Our goal was not to determine if our weight management program improved symptoms of food addiction in adolescents, and the program was not specifically aimed at food addiction; yet, symptoms decreased overall and two of the three adolescents identified as food addicted before beginning the program no longer met the diagnosis criteria following the program. Although limited by the small number of adolescents completing the 12-week program, in particular those who met the criteria for food addiction upon entry, the witnessed reduction in adolescents meeting the criteria for food addiction and decrease in symptoms following weight management treatment were similar to those observed in adults following bariatric surgery. Before surgery, Pepino et al.³⁸ observed a food addiction prevalence of 32%. Six months following bariatric surgery-induced weight loss, remission of food addiction was 93%.³⁸

The weight management program attrition rate of 50% unfortunately replicated attrition rates previously observed with similar programs.^21,23 Across 12 institutions with multidisciplinary, pediatric weight management programs, Rhodes et al. reported an attrition rate of 42% at 3 months.²³ Compared to this study, Lent et al. and Burmeister et al. observed much higher retention of their adult participants overall (86.5% and 89.5%, respectively) in their weight management program. In addition, neither study observed significant associations between baseline food addiction status (and symptoms) and attrition. In this study, however, attendance with the weight management program was significantly lower and dropout rate was significantly higher in the adolescents diagnosed as food addicted. Dropout rate in those meeting the clinical diagnosis for food addiction was 62.5% versus 44.4% in nonfood addicted. The overall significance of this is unclear and, to our knowledge, no other study conducting an outpatient, behavioral weight-loss intervention in adolescents has examined food addiction as a barrier to adherence.

Of the variables examined between the adolescents meeting the criteria for food addiction compared to those who did not, the only significant differences between these two groups were age and HRQOL. Given that differences in HRQOL remained significant between the two adolescent groups after adjusting for age, one may speculate on the potential role HRQOL may have played in the adolescents with food addiction. Did their lower HRQOL affect their attendance and/or ultimately lead them to drop out of the program altogether? Also, as previously mentioned, did their lower HRQOL contribute to their food addiction or the reverse? Or again, it may be mutual interactions among food addiction, excess weight, and poor HRQOL, working together as barriers to behavior change and ultimately leading to poor adherence with a behavior-based, weight management program. Our study provides early evidence that adolescents with food addiction or a greater number of food addiction symptoms may warrant additional resources to support adherence to and retention with a behavioral weight management program.

Implementing screening measures for food addiction diagnosis and symptoms before enrolling in a weight management program may be an effective strategy to identify adolescents who may benefit from alternative or adjunct modalities. For example, a systematic review by Katterman et al.⁴³ found that mindfulness meditation was effective in weight maintenance and reduced binge eating and emotional eating in adults. It is possible that food addiction and higher levels of addictive-like eating behavior might explain some of the inefficacy of current weight programs focusing solely on diet and exercise.¹⁹

Analogies can be drawn from the tobacco addiction literature in adolescents. For example, without effective treatment, adolescent smokers have a spontaneous quit rate of 4.1%.⁴⁴ For those adolescents receiving effective treatments aimed at tobacco cessation, quit rates increase to ∼34%.⁴⁵ Taken together, this suggests that identifying food-addicted adolescents before entry into weight management programs may be essential to optimizing effective treatment as well as maximizing resource allocation. Despite the willingness and desire to lose excess weight, adolescents with food addiction may be unable to mitigate their drive to eat; therefore, interventions directed solely at healthy eating and physical activity may be less effective.¹⁹ Further research is necessary to identify potential effective interventions or treatment strategies for adolescents with a higher number of food addiction symptoms and/or those meeting the criteria for food addiction diagnosis.

This study evidenced interesting findings, but several limitations should be considered. First, the relatively small and predominately Caucasian sample may not be generalizable to a broader population and should therefore be considered an exploratory investigation. Due to the small number of adolescents who completed the 12-week program, in particular those who met the criteria for food addiction upon entry, we were unable to examine the relationship between food addiction and weight-related outcomes. In addition, there are many psychosocial aspects that affect appetitive responsiveness and HRQOL. Depression, anxiety, emotional distress, and self-esteem were not directly measured, and these conditions have been found to be related to higher BMI and HRQOL in children.^28,46

Last, there is ongoing dialogue as to whether food addiction is, in essence, a more severe form of the clinical diagnosis of BED. BED shares several characteristics with food addiction.⁴⁷ However, loss of control over eating is an essential criteria for the diagnosis of BED. In our study, only one of seven participants endorsed loss of control over eating, suggesting that food addiction may represent a unique construct of pathological eating. Ongoing research is necessary to determine if food addiction truly is a distinctly different eating disorder as our results suggest.

Much research is dedicated to identifying variables that affect adherence, attendance, and completion of weight management programs in children and adolescents. Our study suggests that food addiction is a significant barrier to successful weight management for obese youth. Furthermore, it appears that food addiction and a greater number of food addiction symptoms, together, have a significant detrimental effect on other aspects of these children's lives. Although further research is needed, children with a higher number of food addiction symptoms and/or those meeting the criteria for diagnosis of food addiction may require enhanced weight treatment programs to ensure optimal weight-loss success.

Footnotes

Acknowledgments

The authors would like to thank Amy Nickerson, MS, RDN, for her nutrition guidance and instruction with adolescents enrolled in the weight management program. In addition, we would like to thank Michael Lowe, PhD, for the use of the C-PFS.

Author Disclosure Statement

No competing financial interests exist.

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