This interview is brilliant.
I’ve long been wary of extending the boundaries of addiction to food and compulsive behaviors. My concern is that diffusion of the conceptual boundaries of addiction would reinforce stigma. We often hear people describe being addicted to shopping, chocolate, exercise, their phones, social media, sex, gambling, etc. Sometimes the invocations of addiction are describing debilitating compulsions. More often, they are describing excesses or even a love for something. I’ve no doubt that addiction and many compulsive behaviors share many of the same mechanisms. However, I also believe it’s important to protect the boundaries of addiction. My concern is that the over-extension of addiction ends up universalizing addiction, which leads to people saying and thinking things like, “I’m addicted to chocolate, but I have some self-control. Why can’t that person manage their drinking? They must not love their family enough.”
However, Dr. Gearhardt makes the most compelling case I’ve ever heard for the idea that some people experience addiction to highly processed foods. The interview is well worth your time.
On “addictiveness” – For most of my career, I’ve tried to add nuance to people’s understanding of addiction. When I lecture, we talk about addiction as a product of the interaction between the substance and factors within individuals, as well as some environmental factors. We talk about “capture rates”, pointing out that even the substances with the highest capture rates are only associated with addiction in a fraction of users.
In recent years, efforts to destigmatize recovery and addiction have veered into destigmatizing drugs. One theme of that effort is that the addictiveness of drugs is often misunderstood and overstated, that the drivers of addiction really exist in the individual and maybe their environment.
The locus of addiction has swung so far toward the individual that the interviewer repeatedly states that he’s not used to thinking about the addictiveness of various substances. Her exploration of what it means to call something “addictive” and how to evaluate that quality of a substance is very thought provoking and challenges me to identify all my priors.
On the role of substance processing – One continuing education moment that has stuck with me for more than 20 years was Bill White’s response to a question about what substances were likely to become a crisis in the future. He responded that he didn’t know which substance would pose a major problem in the future, but that the substance was already here and someone would come up with a new way to prepare and consume it, and this innovation would transform the relationship between the drug and some of its users. He pointed to opium and the syringe, and the emergence of crack cocaine as examples.
Her discussion of the way food processing concentrates the most rewarding elements in the food is very thought-provoking. Almost as an aside, this point is amplified by her reference to tobacco companies moving into the food industry and promoting highly processed food. She even suggests that some of these foods shouldn’t be categorized as food. Rather, they should be treated as highly refined substances engineered for their reward-inducing properties.
Environmental factors – She characterizes “food insecurity” as a misnomer, suggesting that “nutrition insecurity” is a more apt descriptor because it highlights the role of environmental factors regarding which foods people have access and exposure to. Again, this challenges the idea that addiction is primarily a property of the individual. She highlights how exposure dramatically increases addiction and harms by pointing to tobacco as a public health success story.
On addiction – The exploration of addiction, particularly in the absence of euphoria, is really clarifying. She emphasizes the roles of salience and motivation- that addiction is much more about wanting than liking or pleasure. She identifies four criteria for assessing addictiveness drawn from the surgeon general’s report on tobacco. They are associations with compulsive use, mood-altering effects, reinforcing properties, and inducing craving.
I’d love to hear a smart counterargument. I’m not totally sold, and I want to think through all of the implications, but this is easily the most compelling case I’ve heard in my career. The paper is available here.