Treatment of Food Addiction
Food addiction should be treated using eating disorder-focused cognitive-behavioral therapy (CBT) or interpersonal therapy, with consideration of therapeutic carbohydrate reduction and harm reduction approaches, as food addiction represents a severe phenotype of binge eating disorder with significant psychiatric comorbidity. 1, 2, 3
Understanding Food Addiction as a Clinical Entity
Food addiction functions as a proxy for severe eating disorder pathology, particularly binge eating disorder, with greater trauma histories, PTSD symptoms, and psychiatric comorbidity than typical eating disorder presentations. 4 This recognition is critical because it indicates that standard eating disorder treatment protocols apply, but may need augmentation for the addiction component. 5
First-Line Treatment Approach
Initiate eating disorder-focused cognitive-behavioral therapy (CBT) as the primary treatment, delivered in individual or group formats, focusing on normalizing eating behaviors and addressing psychological aspects of the disorder. 1, 6
Consider interpersonal therapy (IPT) as an alternative psychotherapy option if CBT is not preferred or available, as both have demonstrated efficacy for binge eating pathology. 1
Implement a harm reduction model specifically designed for food addiction that addresses both addiction and disordered eating features, rather than strict abstinence or unrestricted moderation approaches. 3, 5
Treatment Selection Algorithm
Step 1: Initial Assessment
Quantify eating patterns and frequency of binge episodes using the modified Yale Food Addiction Scale (mYFAS 2.0) to establish food addiction diagnosis. 5
Obtain complete blood count and comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests. 7, 8
Screen for trauma history, PTSD symptoms, and psychiatric comorbidity (depression, anxiety, substance use disorders), as these are significantly elevated in food addiction. 4, 5
Perform electrocardiogram in patients with severe purging behaviors or those taking QTc-prolonging medications. 7, 8
Step 2: Choose Treatment Intensity Based on Severity
Outpatient psychotherapy for mild-to-moderate food addiction without medical complications. 1
Residential treatment for severe food addiction with significant psychiatric multi-morbidity, trauma-related disorders, or co-occurring substance use disorders. 5
Step 3: Select Dietary Approach Within Psychotherapy Framework
Offer one of three evidence-based dietary strategies:
Treatment as usual (TAU): Standard eating disorder dietary approaches with regular meal patterns and no food restrictions. 5
Harm reduction (HR): Support in decreasing consumption of ultra-processed foods (UPFs) or particular identified trigger foods, allowing gradual reduction rather than complete elimination. 3, 5
Therapeutic carbohydrate reduction (TCR): Metabolic health intervention emphasizing carbohydrate reduction, which has shown 40.7% reduction in food addiction symptoms and 34.7% reduction in binge eating symptoms. 2
Pharmacological Augmentation
Add lisdexamfetamine 50-70 mg daily for patients who prefer medication or show minimal response to psychotherapy alone after 6 weeks, as this is the only FDA-approved medication for binge eating disorder. 1, 6
Consider selective serotonin reuptake inhibitors (SSRIs) as an alternative medication option, though evidence is more limited than for lisdexamfetamine. 1
Naltrexone may target opioid-mediated craving mechanisms in food addiction, though this is off-label use and requires careful monitoring for hepatotoxicity with doses above 50 mg. 9, 10
Multidisciplinary Team Coordination
Assemble a coordinated team incorporating medical, psychiatric, psychological, and nutritional expertise, including a primary care physician, mental health practitioner, and registered dietitian. 7, 8, 1
Integrate trauma-focused treatment when trauma history or PTSD symptoms are present, as food addiction strongly correlates with complex trauma. 4, 5
Technology-Based Treatment Options
Offer technology-based CBT interventions (guided online programs, telemedicine with text-based communications, asynchronous education) for patients with limited access to specialized care, as these show medium to large effects for reducing binge eating behaviors. 7, 2
Ensure guided interventions rather than pure self-help, as support improves outcomes and adherence. 7
Monitoring and Follow-Up
Track food addiction symptoms using mYFAS 2.0 scores at regular intervals to assess treatment response. 5
Monitor binge eating frequency, psychological distress, weight changes, and medication adherence. 1
Reassess psychiatric comorbidity (depression, anxiety, PTSD symptoms) as these often improve with food addiction treatment. 4, 5
Critical Pitfalls to Avoid
Do not apply pure abstinence models from substance use disorder treatment without considering the disordered eating features, as complete food restriction can worsen eating pathology. 3, 5
Do not use unrestricted moderation approaches alone for severe food addiction, as this ignores the addiction neurobiology and often fails in patients with high mYFAS scores. 3
Do not overlook trauma assessment and treatment, as food addiction strongly correlates with trauma history and PTSD, and untreated trauma predicts poor outcomes. 4, 5
Do not delay treatment while debating whether food addiction is "real", as patients meeting mYFAS criteria have demonstrably worse eating disorder severity, obesity severity, and psychiatric comorbidity requiring immediate intervention. 4