Can Obesity Be an Addiction?

Bret S. Stetka, MD; Nora D. Volkow, MD


July 16, 2013

In This Article

The DSM, Video Games, and DC Traffic

Medscape: On a related note, I know it was somewhat controversial that DSM-5 included specific addictive behaviors, such as Internet gaming addiction. Do you feel that calling out specific addictions like this is warranted? Or in theory, aren't there an infinite number of behaviors one could be addicted to?

Dr. Volkow: There actually appear to be a limited number of behaviors which can result in addiction, much like drugs. There are only a few chemical compounds that can produce addiction. You can't get addicted to antibiotics, or antidepressants. Only chemical compounds that increase dopamine activity in reward pathways can produce addiction. Similarly, only behaviors that increase dopamine in the NAc (ie, gambling) can result in addiction with repeated exposures in those that are vulnerable. The same is true with food; as a result, not all foods are equally rewarding.

If you eat an overboiled piece of chicken, it can be rewarding, but only if you are hungry. But if you are not hungry, it may not be inherently rewarding. On the other hand, many would find a chocolate chip cookie inherently rewarding, even in the absence of hunger. This makes some foods much more dangerous in promoting reward-system activation and causing compulsive eating behaviors.

The same goes for such behaviors as video gaming, which is inherently reward-based. You get the reward of winning, or beating your enemy. And gambling is obviously reward-based. But driving a car, for example, in the middle of rush hour in Washington, DC, will never generate an addictive behavior!

Medscape: I know you were a proponent of including obesity caused by addiction in the DSM-5. In the end, it wasn't included in the revised manual, but do you still feel it should have been? And do you think ultimately it will be included as more data come to light?

Dr. Volkow: During the DSM-5 development, Chuck O'Brian and I brought forward the similarities between addiction to drugs and obesity from overconsumption of palatable food, both in terms of clinical presentation and neurocircuitry. We saw it as an opportunity for psychiatrists to consider the addictive component of obesity and help in developing therapeutic interventions. Specifically, we thought psychiatry could play an important role in the behavioral element of overeating behaviors, but obesity didn't get incorporated into the DSM-5. Some were concerned that including obesity as a mental illness would increase its stigmatization. On the other hand, I was delighted when the AMA declared obesity a disease.

Medscape: Is there much support in the medical community for one day including obesity in the DSM?

Dr. Volkow: I don't know. Societies that develop diagnostic criteria have committees with long-standing procedures and opinions regarding the diseases they are classifying. There is a section in the DSM on eating disorders, which includes bulimia and anorexia nervosa. Of note, DSM-IV (and DSM-5) consider binge eating disorder a mental illness, but not obesity. But I do foresee that eventually -- and particularly now that the AMA considers obesity a disease -- perhaps in the next round of revisions, certain types of obesity (ie, that not associated with endocrine dysfunction) may be considered for inclusion in DSM.

Medscape: Do you have any sense as to what percentage of obesity is caused by addictive pathology?

Dr. Volkow: I do not have any data, but I would predict that most of the problems of being overweight and obesity in our country are driven by excessive consumption of rewarding food. However, just as is the case for drugs, for which most of the consumption is not by people who are addicted, I would predict that most cases of overeating are in people who are not addicted to food.


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