From cigarettes to obesity, public health at risk
By Mark S. Gold, MD
Public health officials and academics identified cigarette smoking and related disease as the nation’s number one killer and foremost driver of health costs in the 1980s. At that time overeating and obesity were not major problems, yet they may soon cause more disease, deaths, and health care costs than cigarettes. Food addiction, which may explain part of the epidemic, is slowly and finally “catching on”. It’s been controversial, with some scientists dismissing it out of hand, so like any hypothesis, it needs additional tests.
If overeating is due to food acquiring drug-like or tobacco-like brain reinforcement properties, then the current globesity and overeating-related health crisis might have lessons to learn from tobacco. For example, taxes on tobacco products have been the single most important prevention tool in reducing smoking. Based on food addiction hypothesis, higher prices might also reduce soda consumption. A review suggested that for every 10% increase in price, consumption decreases by 7.8%. An industry trade publication reported even larger reductions; as prices of carbonated soft drinks increased by 6.8%, sales dropped by 7.8%, and as Coca-Cola prices increased by 12%, sales dropped by 14.6%. It follows that a tax on sweetened beverages might help consumers switch to water or more healthful beverages. Such a switch would lead to reduced caloric intake, and less weight gain.
Changing the attitudes and behaviors of the public combined to reduce smoking and smoking-related health care costs and suffering. Changing access to cigarettes by elimination of cigarette vending machines, raising the price per pack to decrease numbers of cigarettes or packs/day smoked, crafting PSAs to reduce smoking initiation, and training medical professionals to intervene and not look the other way, all helped reduce smoking.
Age of onset and exposure can change genes, and make use and addiction more likely. We know that early exposure to tobacco via second-hand-smoke, either in utero or in early life greatly increases the risk of life-long tobacco use and addiction. In the 1990s, children’s intake of sweetened beverages surpassed that of milk. In the past decade, per capita intake of calories from sugar/HFCS-sweetened beverages has increased by nearly 30%. Beverages now account for 10–15% of the calories consumed by children and adolescents. It is likely that food addiction models can be used to explain early exposure and changes in preference becoming fixed and persistent for life. An extra can or glass of sugar or HFCS sweetened beverage consumed per day increases the likelihood of a child’s becoming obese increases by 60%.
Our efforts to manage and treat overeating and obesity might benefit from addiction methods and experience. We could develop realistic food addiction models and test new treatments. Would animals self-administer food or food constituents, avidly, with bingeing and loss of control? Yes. Our work (and Bart Hoebel’ s before) clearly demonstrates that sucrose and fructose corn syrup are self-administered as if they were drugs and that an opiate-like abstinence syndrome could be produced by detoxification or antagonist administration. Sugar stimulates its own taking causes craving, wanting, withdrawal, and can motivate and change our behavior.. If the food addiction hypothesis were relevant to the human condition, these animal models could be used to test new medications. New treatments developed for overeating and obesity were previously shown to be effective in addiction medicine.
These new treatments approved by the FDA include phentermine plus topiramate and bupropion plus naltrexone. Topiramate has been used with success in alcohol dependence, bupropion in nicotine dependence, and naltrexone in opiate and also alcohol dependence. While early, these treatments are important tests of the addiction hypothesis and harbingers of more progress in the future. With addiction medicine and food addiction model systems, we may develop treatments which change food preference and not just appetite.
Food addiction may explain some, but certainly not all obesity. The Yale Food Addiction Scale may be used to screen patients for addiction-like pharmacological and psychological interventions. Medically-assisted smoking cessation efforts were enhanced once treatment advanced from simple nicotine replacement or detoxification, to the brain and the neurobehavioral attachment to cigarettes. With an addiction hypothesis that included dopamine, we discovered the efficacy of bupropion and then Chantix. Thus, rather than a successful short term treatment rate of less than 20%, we routinely helped 30% of smokers. Still, addiction-inspired public health measures rather than medically-assisted treatment were responsible for most of the successful cessation efforts, early intervention, and prevention.
Smoking-related disease caused 400,000 deaths per year in the USA plus an additional 40,000 deaths due to second-hand smoke. Until recently little effort was directed at preventing smoking or treating smokers, although we treated the lung cancers, stroke, erectile dysfunction and other diseases caused by smoking. With all this progress, all of the health savings related to smoking cessation will soon be replaced by obesity-related costs. Are these two events related? As smoking and addiction is associated with decreases in eating and weight, a nation detoxifying from smoking addiction should be expected to become overweight. Until recently, with the scientific support provided by food and addiction models, we have not applied the same lessons learned from tobacco to overeating and obesity.
Proposals for food taxes have been made and calculations formulated of revenue-benefits based on our experiences with tobacco taxation. Even when these fail, the public and health experts have to think through the idea that fruits and vegetables are more costly than fatty, sweet, fast foods. Using taxes on ingredients such as added sugar and fructose corn syrup would decrease exposure according to addiction models. This might make Coca-Cola and other sodas return to sucrose as in Mexican or Kosher Coke. Reducing portion size, while supported by cigarette experience with numbers of cigarettes per pack and purchase limits, is a weaker intervention than other approaches. Now we see food labels and calorie postings. This educates everyone as they consider is it worth the calories and do they have the time and energy to exercise away the calories ingested. Exercise is important, and promotes health, but is not a stand-alone obesity treatment or management strategy. Stigmatizing the overweight with added health premiums and workplace incentives has not worked well in the past. Blaming the patient, creating shame and guilt, doesn’t do much to inspire treatment efficacy.
Obesity has changed the width of the seats in airplanes, dress, and trouser sizes. It has also made high cholesterol, high blood pressure, high blood sugars, knee and joint pain, and other obesity-related problems routine in medical practice and treatment. Over the past three decades, rates of obesity have increased in the United States and elsewhere, so that now more people are obese and in need of treatment than ever. New approaches, evidence-based approaches, like those that have been used successfully to develop novel public health and treatment approaches for tobacco, alcohol, and other addictions are needed.
Mark S. Gold, MD is the co-editor of Food and Addiction: A Comprehensive Handbook with Kelly D. Brownell. He is the Donald Dizney Eminent Scholar, Distinguished Professor and Chair of Psychiatry at the University of Florida. Dr Gold is a teacher of the year, researcher and inventor who has focused for much of his career on the development of models for understanding the effects of tobacco, cocaine, opiates, other drugs, and also food, on the brain and behavior. He began his work on the relationship between food and drug addictions while at Yale working with addicts in withdrawal. He has worked for 30+ years trying to understand how to change food preferences, make eating and drugs of abuse less interesting or reinforcing at the brain’s dopamine and other reinforcement sites. Kelly D. Brownell, PhD is professor of psychology, epidemiology, and public health at Yale University and is director of Yale’s Rudd Center for Food Policy & Obesity. Dr. Brownell does work at the intersection of science and public policy. The Rudd Center assesses, critiques and strives to improve practices and policies related to nutrition and obesity so as to inform the public and to maximize the impact on public health.
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Image credits: (1) Young mother and her baby, sleeping in bed. Photo by SvetlanaFedoseeva, iStockphoto. (2) Shrimp cocktail elegantly served in a martini glass accompanied by a glass of white wine. Photo by sbossert, iStockphoto.