Abstract

Background: Childhood obesity rates have been rising in the last years as well as publications containing information about the relationship with food addiction. Experts have found a similarity between food addiction and drug addiction, and how it mostly affects children and adolescents.

Objective: To analyze the most recent literature looking for scientific evidence explaining the existing relationship between the consumption of highly palatable foods and how it can lead to addictive food behaviors in children and adolescents.

Methods: Seven articles were selected after conducting a systematic literature review using google scholar and CINAHL. The articles were primary studies conducted in the pediatric population who reported a food addiction behavior using the Yale food addiction scale.

Results: The most relevant and popular finding among the studies was the fact that food addiction symptoms were more present among children and adolescents who had a high BMI and/or were going through a weight loss treatment program.

Conclusions: There is adequate evidence to conclude that highly palatable foods which contain high amounts of fat and sugar can lead to addictive behaviors in children and adolescents. Therefore, there must be more strict and focused intervention from a multidisciplinary team when dealing with a similar situation. More longitudinal and prospective studies should be done in order to confirm these findings and acquire more information about possible long-term adverse effects.

Introduction:

Childhood obesity has become one of the most alarming issues occurring in our society. The center for disease control (CDC) indicates that the prevalence of obesity for children and adolescents aged 2-19 years old is 18.5% and affects about 13.7 million.1 It is undeniable that society and the environment play an essential part in encouraging the overconsumption of highly palatable foods. These kinds of foods may lead children and adolescents to have a tendency towards food addiction. Food addiction symptoms are characterized by loss of control over consumption, continued use despite adverse consequences, and an inability to cut down despite the desire to do so.2

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Food addiction has become a point of attention from contemporary media. The number of publications related to this issue has increased tremendously since 2000.3 The first record of addictive eating behaviors towards food was reported in a scientific journal in 1890 when chocolate was described as food with potential generate these addictive behaviors. Then several years after that the term “chocoholic” became popular. 3,4

The addictive consumption of highly palatable foods is due to their high hedonic properties such smell, taste, and appearance which are processed at the mesolimbic dopamine (DA) reward pathways in the brain, which is the same pathway in charge of the behavioral and neurophysiological effects of addictive drugs.5,6There is a great debate around this issue because unlike known addictive drugs, we cannot live without eating.6 This problem is more relevant to children because kids nowadays have easy access to fast foods, and the industry often targets them from an early age in order to make them dependable of a specific food item their whole life. Children are more vulnerable to food-addictive behavior than adults because, in times of stress, children do not have easy access to any drugs, but to hyperpalatable foods.7 In contrast, adults have easy access to drugs that provide them with pleasure and reward such as tobacco, alcohol, or other drugs. Especially during adolescence, kids will use hyperpalatable foods as comfort foods, which can yield excess calories and eventually may lead them to be obese.

The goal of this literature review is to collect enough research evidence that allows us to analyze if the consumption of highly palatable foods can lead to addictive food behaviors in children and adolescents. Therefore, the research question is:

What is the relationship between consuming palatable food and the risk of food addiction in children and adolescents ages 0 through 21?

In order to complete this summary review, a total of 7 original research articles focusing on food addiction in children and adolescents were reviewed.

Literature Review:

Food addiction and the Yale food addiction scale:

The Yale food addiction scale (YFAS) is a questionnaire composed of 25 multiple choice questions that was developed in 2009 to categorize and identify those who are most likely to be exhibiting markers of substance dependence with the consumption of high fat/high sugar foods. This tool is based on the seven substance dependence criteria in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV. 8 During the questionnaire, participants usually have to focus on the past 12 months when they answer the questions. There is a preselected number of categories from which the participants can choose when answering a specific question. The choices range from ‘never’ to ‘four or more times a week or daily’) and dichotomous scoring (‘yes’ or ‘no’). The Yale Food Addiction Scale for Children (YFAS-C) was recently developed in order to measure food addiction in children due to the rising of childhood obesity. The differences between this new version and the adult one is that the children scale has been redesigned, with appropriate wording and age-appropriate activities, for instance, employment type has been substituted by school, and other categories like parental interactions have been added, many responses have been edited for easier comprehension , and the most important change is that for some question the reading level has been lowered . 8,9

Addictive-like foods:

Our food environment has been in constant change compared to 50 years ago. Food now has a higher level of processing, higher level of additives and preservatives to assure acceptance and shelf life. The industry has become more concerned each day about sales and acceptability of the products by the targeted population, and they will try to add as many food additives as possible in order to increase sales.3 This topic has created a great deal of contradiction and polemic across the scientific community because some people state the fact that there is not such a thing as food addiction since food is necessary for our health and survival.3 However there is enough evidence to state that hyperpalatable foods can be as addictive as drugs. For instance, hyperpalatable foods can activate the dopamine and opioid circuitry inside the brain, which can trigger artificially elevated levels of reward. Many of the foods contain a high amount of sugar or other simple carbohydrates that can be absorbed quickly into the bloodstream, which can alter neurobiological systems. Another similarity with drugs is the fact that these foods are commonly eaten despite harmful consequences and despite a desire to cut down, and they can also induce cue-triggered cravings.3,10

The Reward System :

The brain has a specific region for each of its functions, many addictive drugs have habit-forming action that can be localized in a specific area, and they can activate their corresponding reward circuitry in the brain. The mesolimbic dopamine system or mesolimbic pathway is considered the region that plays an essential role in the progress and maintenance of an addiction.11 The mesolimbic pathway is composed of many dopamine-releasing cells or (dopaminergic ) that send signals from the ventral tegmental area to the ventral striatum. The mesolimbic pathway is the one that enhances motivation and cognition, especially when a specific action would end up in a reward.11 The higher the dopamine levels mean higher gratification or pleasure perception. 12Other structures that form part of the reward system are nucleus accumbens, the septum, the amygdala, and prefrontal cortex. When comparing this with food addiction, it works similarly. Many of these studies of food addictions have been done with rats since we share the same reward system on the brain. It was discovered through these experiments that sweetened water activates midbrain dopamine neurons which then releases dopamine in the ventral striatum. The sweet taste can also activate other brain areas that are usually activated by substances of abuse, for instance, the ventral palladium and the orbitofrontal cortex which is functionally linked to the insular gustatory cortex. 13

Methods:

A total of 7 articles were selected after conducting a literature search using PubMed, google scholar, and CINAHL. Some of the key terms utilized for the search were food addiction, children, childhood, adolescents, highly palatable foods, obesity, overweight, YFAS, and DSM-IV. The articles were primary studies conducted either with pediatrics population or with the parent or legal guardian of a child. Most of the studies used the YFAS questionnaire, among other significant measures like age, weight, height, ethnicity, and BMI. The publication years of the mentioned studies ranged from 2009-2018.

Pretlow 7conducted a qualitative cross-sectional study among teens and preteens ages 8 to 21. The purpose of this study was to examine why an overweight-intervention open-access website launched in 1999 was not successful in influencing weight loss in adolescents. Data was collected anonymously because adolescents are embarrassed to talk face to face about their weight with peers. Bulletin boards, chat rooms, and multiple-choice pools were used to gather data. Only those whose BMI was higher than or equal 85th percentile were able to post messages in the chat rooms, while the polls did not have any restrictions. A total of 29,406 anonymously unique users posted 41,535 bulletin board messages and 93,787 replies from June 2000 to September 2010. Females participants counted a 94 %, only 5% were male, and for the missing 1%, sex was unknown. The data obtained were analyzed qualitatively for common denominators in weight loss failure and success. The multiple-choice options were quantitatively analyzed. One of the strengths of this study was the use of anonymity, which led to honesty during the responses.

Merlo et al. 9 also conducted a cross-sectional study research with the pediatric population to analyze the factors that may be associated with food addiction during childhood. A total of 50 children and their parent /guardian were recruited from the Pediatric Lipid Clinic at a large southeastern teaching hospital. The ages of the children that participated in the study ranged from 8-19 years old. Children were divided into male and females’ subgroups; they were also categorized by their ethnicity and their BMI was obtained using the Centers for Disease Control (CDC) BMI Calculator for Child and Teen individuals. Their parent/guardian were also divided into male and female subgroups and by ethnicity. Parents also reported marital status and average annual family income. The measures were done by using different assessment created by the authors, among them were Attitudes Test (EAT), Children’s Eating Attitudes Test (ChEAT), Three-Factor Eating Questionnaire (TFEQ), Inventory of Overeating Situations (IOS), Eating Behaviors Questionnaire (EBQ). For the data analysis the following measurements were used: 1) assessment of correlations among parent and child scores for the same variables, 2) evaluation of the association between various eating behaviors and attitudes with BMI ratings for pediatric patients, and 3) exploration of eating behaviors and attitudes associated with self-endorsed symptoms of food addiction among pediatric patients.

In the study done by Meule et al. 14 , the authors aimed to apply YFAS and other questionnaires in a sample of 50 overweight and obese adolescents who were recruited from weight-loss treatment in a rehabilitation hospital in Germany. Patients were approached individually, and they were asked to answer a variety of questionnaire. The YFAS is composed of different scoring options to indicate the experience of addictive eating behavior within the past 12 months. Another measure was the Food Cravings Questionnaire (it measures the frequency and intensity of food craving experiences). An Eating Disorder Examination Questionnaire was also one of the measures that analyzed eating disorder psychopathology. The Barratt Impulsiveness Scale was a short form that was used to measure trait impulsivity on a four-point scale ranging from rarely/never to almost always/always. For the last measure, they used the Center for Epidemiologic Studies Depression Scale, which measures depressive symptoms within the past week.

Schulte et al. 2 utilized a cross-sectional design in order to identify which foods were most likely to be consumed in an addictive way. The authors conducted two studies:

In study one, 120 participants were recruited from the University of Michigan either through flyers or through an introductory psychology subject pool. Participants were aged 18 to 23 years old. Participants had to complete YFAS questionnaires. To complete the questions, the participants were asked to think about foods high in fat or refined carbohydrates when they read the phrase “certain foods”, in the questions. Then the participants were presented with two pictures at once from a 35-picture bank, and they were asked to select which one they had trouble with. In the end, the participants reported demographic information and ethnicity, gender and weight, and height were taken.

In study 2: A total of 398 participants were selected through Amazon’s Mechanical Turk (MTurk). Each participant was compensated $ 0.40 for their time. The authors decided to follow a strict set of inclusion criteria; for instance, the weight had to be less than 900 lbs. , they had to be between 18 to 64 years old, they needed to provide their gender and answer correctly to specific catch questions that identified if the individuals were answering questions without correctly reading. Participants completed the same version of the YFAS. Then rather than comparing each food against another to identify the one that caused more trouble like in study one; participants were asked to rate how likely they were to experience problems with each of the 35 foods in the bank. Participants also reported demographic information, ethnicity, gender, as well as weight and height.

Burrows et al.15 conducted a cross-sectional survey to analyze and understand the factors associated with addictive eating behaviors in children as reported by their parents. The participants for this study were parents or principal caregivers of 5 to 12-year-old children recruited through Amazon Turks. A total of 163 parents/ primary caregivers currently residing in the U.S. and each of them were paid $0.50 for completing the survey. The survey consisted of 146 questions that asked the parents and caregivers to report demographics, addictive eating behaviors and parental feeding practices about themselves and demographics and addictive eating behaviors; dietary intake and demographics about their children. Food addiction scores for parents were determined using the adult version of the YFAS. Parent’s feeding practices were assessed using the Child Feeding Questionnaire (CFQ). Chi-square, t-tests, and ANOVAs were applied to investigate the differences in frequency of food addiction symptoms, food addiction diagnosis and the relationship with demographic variables, feeding practices and the weight status of both children and parents.

In another cross-sectional design study done by Falbe et al. 16 they tried to examine the potentially addictive properties of sugar-sweetened beverages (SSBs) in the overweight and obese adolescent population. A total of 25 participants between the ages of 13-18 years old with a BMI of≥85 percentile for age and sex. In order to be included in the study, the participants had to speak English and have a parent or guardian who spoke English or Spanish. Adolescents were excluded from the study if they were either pregnant, nursing or undergoing mental health treatment. During Phase 1 of the study, participants were instructed to continue drinking their usual beverages for 5 days. Then for phase 2 the cessation period they were allowed only to drink plain water or plain milk. Participants were reimbursed for traveling, and they received $160 for their participation. The measures during the study were primary for the symptoms of withdrawal and craving with a scale that recorded mood change, behavior, and physical symptoms. The authors focused on withdrawal because it maintains the continued use of a substance to alleviate symptoms, and cravings predict the frequency of substance use and relapse. Many of these symptoms occur in response to cessation from high sugar intake evidenced by animal model. The withdrawal scale was assessed with Cronbach’s alpha.

Rocha Filgueiras et al. 4 this article is a cross-sectional study done in the city of Sao Paulo, Brazil. A total of 139 children from both sex and ages 9 to 11 that were enrolled in a low-income school were included. Parents/guardian had to provide written consent for their children’s participation in the study. The inclusion criteria in the study were the presence of excessive body weight. The exclusion criteria were the presence of any cognitive or physical delay, taking medication, which, the apparent side effect was body weight management and those with a family issue that could affect compliance with the study. Some of the measures used were the ale Food Addiction Scale for Children (YFAS-C). A dietary assessment was used using the semi-quantitative food frequency questionnaire. Quantification and classification of foods in which data on food intake was converted to energy and nutrient data. Pubertal staging, as well as socioeconomic status, were measured, the authors also measured anthropometrics and blood samples were used for biochemical analyses.

See TABLE 1 for summary of results.

TABLE 1: Summary of results from collected literature

Authors

Results

Pretlow et al. 7

54% of respondents (n = 52) stated that they usually do mindless eating when they were stressed or bored.

 Many of the posts exhibited at least 3 criteria that meet DSM-IV substance dependence (addiction) criteria by the American Psychiatric Association (1994):

a) large amounts of substance consumed over a long period, b) unsuccessful efforts to cut down, and c) continued use despite adverse consequences.

As classical with drugs, it was found that 77% of respondents (n = 92) indicated they ate more now than when they first became overweight.

Merlo et al. 9

 The BMI ratings of the kids were significantly correlated with overeating (r = .42, p = .02) and emotional eating (r = .33, p = .04).

 The children’s total scores on the ChEAT were significantly related to the parents’ scores on the EAT (r = .39, p = .009).

Food addiction symptoms were significantly correlated with child overeating (r = .64, p < .001). uncontrolled eating (r = .60, p < .001), emotional eating (r = .62, p < .001), food preoccupation (r= .58, p < .001), overconcern with body size (r = .54, p < .001), and caloric awareness and control (r = −.31, p = .04).

Meule et al. 14

 Most common food addiction symptom was a persistent desire or repeated unsuccessful attempts to cut down consumption.

Adolescents with a YFAS diagnosis had higher eating, weight and shape concerns.

They also reported more days with binge eating incidents and food craving experiences.

The also had more symptoms of depression and scored higher on attentional and motor impulsivity than individuals without a YFAS diagnosis.

Schulte et al. 2

For study one:

Food with a high level of processed or added amounts of fat and/or refined carbohydrates (chocolate, pizza, cake) appeared to be associated with problematic addictive-like eating behaviors.

For study two:

Consistent with study one, highly processed foods, or foods with added quantities of fat and/or refined carbohydrates had greatest association with addictive-like eating behavior.

 BMI and YFAS symptom count were small to moderate positive forecasters for this association.

Fat and Glycemic Load were significant positive predictors of problematic food ratings.

Burrows et al. 15

In children, food addiction was significantly associated with higher child BMI z-scores.

Kids with higher food addiction symptoms had parents with higher food addiction scores.

The parents of food addictive children reported higher levels of pressure and restriction to eat feeding practices, but not monitoring

YFAS-C scores may be at larger risk for eating-related issues in children.

The YFAS-C score is at risk or the person?

Falbe et al. 201816

During cessation of sugar-sweetened beverages, adolescents, reported an increased craving for those drinks.

Adolescent experienced headaches and impaired ability to concentrate.

During cessation, participants reported lower total daily consumption of sugar (−80 g) and added sugar (−16 g) (Ps < 0.001).

Rocha Filgueiras et al. 4

From the 139 children, 24% had a diagnosis for food addiction.

The “food addictive-group” displayed, on average, 14 grams higher intake of added sugar per day than the non-food-addicted group.

The eating of cookies/biscuits (OR=4.19, p=0.015) and sausages (OR=11.77, p=0.029) were independently associated with food addiction.

The intake of added sugar was also positively correlated (r=0.27, p=0.001) with constant use of the substance despite the knowledge that it was causing or leading to a physical or psychological problem.

Discussion:

First, it is important to summarize addiction-related behaviors related to drugs (for example craving, withdrawal) also found when consuming HP foods. From the results presented by Schulte et al.2 they showed that highly processed foods with a high amount of fat, sugar, and white flour were reliable indicators of food addiction. These ingredients are usually what makes a food item to be highly palatable. These results were congruent with the results obtained by Rocha Filgueiras et al. 4 , which pointed out that cookies/biscuits and sausages were the most problematic addictive foods. Schulte et al. 2 results also support this, because they found that the amount of Fat and the Glycemic Load of the food item were significant positive predictors of problematic food ratings. Falbe et al.16 found that children experienced withdrawal symptoms such as headaches and impaired once they stopped the consumption of sugar-sweetened beverages. These are the same symptoms present when an individual is going through a drug withdrawal.

The second aspect to focus to answer the research question is the association between the feeling of negative emotions and the consumption of highly palatable foods. The results found by Rocha Filgueiras et al. 4 show that the continued intake of added sugar correlated to the uncontrolled overuse of the substance, even though that it was causing or leading to a physical or psychological problem. Pretlow et al. 7 also found that participants stated with their own words they felt bad and unhappy with their body image, and still could not control the desire for eating. Rocha Filgueiras et al. 4 also pointed out that children who met the criteria for food addiction also consumed more sugar on average that the children who did not meet the criteria. This is problematic because if highly palatable foods are effective to relief negative emotions, children can develop patterns of dependency on these foods.

Another interesting finding was according to A. Meule et al. 14 and Merlo et al. 9, children eating attitudes test significantly correlated to their parents. This led us to the conclusion that there is a parental influence when it comes to eating patterns and that children may adopt a similar eating pattern as their parents.

Finally, it is essential to mention the evidence that shows how negative physical characteristics are related to feeling addictive patterns regarding food. From the seven articles reviewed, Merlo et al. 9 and Burrows et al. 15 independently concluded that food addiction symptoms might be more prominent in children and adolescents who are obese or overweight as well as in adolescents who are currently seeking weight reduction treatment. Meule et al. 14 also found a similar result with adolescents with an addiction diagnosis based on YFAS. They had higher eating, weight, and shape concerns and reported higher depression symptom when compared to adolescents who did not had a YFAS diagnosis of addiction.

Conclusions:

It has been demonstrated that childhood obesity has become a prominent issue in our society. After reviewing and discussing the results from the above-selected articles, it was found that there is enough evidence to say that the consumption of highly palatable foods could lead to food addiction. These food addictions symptoms are more evident if the child is either overweight/obese or trying to lose weight or going through permanent or temporary stressful situations. However, it is a complicated health condition to tackle because it is dependent on both social and environmental conditions specific to every child and as well the diet that the individual consumes.

Very little is known, both by society and professionals, about the topic of food addiction in kids and adolescents. This lack of knowledge prevents the successful creation of programs to help eradicate childhood obesity. There must be more emphasis from the health working force (doctors, nurses, dietitians, and behavioral health) placed into food addiction and how to help children control it. Additionally, all the articles reviewed highlighted the lack of recommendations as to what to do to tackle or decrease food addiction symptoms or how to decrease stressful situations in order to avoid the upcoming symptoms. Therefore, to eradicate food addiction the scientific community needs to place the significant findings more accessible to the affected population, and they need to give them the necessary tools to confront the issue otherwise this addiction will keep growing unstoppable. More prospective and longitudinal studies have to be done in order to acquire and confirm these findings and to know what other possible long-term adverse effects of this addiction in children are.

References

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Filgueiras AR, de Almeida, Viviane Belucci Pires, Nogueira PCK, et al. Exploring the consumption of ultra-processed foods and its association with food addiction in overweight children. Appetite. 2019;135:137-145.

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Dr. Micheline Vargas, DrPH, CNS, RCEP. Highly palatable foods: The brain reward pathways and connections to overeating. https://integrativerd.org/wp-content/uploads/2012/04/Highly-Palatable-Foods-slides.pdf Web site. . Accessed 07/03/, 2019.

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Burrows T, Skinner J, Joyner MA, Palmieri J, Vaughan K, Gearhardt AN. Food addiction in children: Associations with obesity, parental food addiction and feeding practices. Eating Behav. 2017;26:114-120.

Falbe J, Thompson HR, Patel A, Madsen KA. Potentially addictive properties of sugar-sweetened beverages among adolescents. Appetite. 2019;133:130-137.