Psychological differences in food addiction and binge eating in non-clinical population

doi:10.21203/rs.3.rs-4803586/v1

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Psychological differences in food addiction and binge eating in non-clinical population

https://doi.org/10.21203/rs.3.rs-4803586/v1

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The aim of the study was to identify the prevalence of food addiction (FA) and binge eating (BE) in a nonclinical population, to explore the differences between these constructs, and to examine psychological differences among individuals with any disordered eating pattern (FA, BE, and FA+BE groups).

Participants aged 18 to 55 completed the questionnaires: Yale Food Addiction Scale (YFAS 2.0), Binge Eating Scale (BES), The PTSD Checklist for DSM-5 (PCL-5), Life Events Checklist, Adverse Childhood Experiences (ACE), Short Impulsive Behaviour Scale (SUPPS-P), Dutch Eating Behavior Questionnaire (DEBQ) and Depression, Anxiety and Stress Scale (DASS-21). Out of 2123 records, 492 participants met the criteria for FA, BE, or both diagnoses.

The present study showed that FA and BE symptoms are common in the general population. The FA, BE and FA+BE groups differed from the control group with respect to the YFAS score, BES score, BMI, negative urgency, restrained eating, emotional eating, depression, anxiety, stress, ACE, PCL, and LEC scores. On all those scales, participants with at least one eating disorder achieved significantly higher scores. The FA+BE group presented the most severe pattern of behavioral and emotional symptoms, followed by the FA group and then the BE group with the least amount of symptoms.

This study supports the operationalization of food addiction. FA is a broader concept than BED, with individuals experiencing both indicating the greatest functional difficulties. Trauma-related experiences frequently accompanied the symptoms, providing insight into disordered eating mechanisms. Future research should include the treatment implications of food addiction for BE patients.

Biological sciences/Psychology

Health sciences/Health care

food addiction

binge eating

eating disorders

dysregulated eating

psychological functioning

Excessive food consumption is a worldwide problem. While most studies examine clinical populations like patients with eating disorders (EDs) or obesity¹, the phenomenon also occurs among people in the nonclinical population^2,3. It has increasingly highlighted the importance of exploring problematic eating behaviors such as the binge-eating spectrum.

Binge eating (BE) is defined as the occurrence of sudden episodes of excessive food consumption in a discrete period of time with a sense of lack of control over eating⁴. The episodes may be preceded by emotional distress and could be a strategy to avoid disturbing thoughts and emotions^5,6. While loss of control characterizes BE, this phenomenon differs from the concept of loss of control in addictions⁷. Uncontrolled binge is explained by a combination of nutritional deprivation and psychological mechanisms such as violating dietary restraints.

While binge eating disorder (BED) is currently categorized in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), some individuals with BED describe binge eating as a form of “food addiction” (FA)⁸. FA is defined as increased compulsive food intake, which in turn may lead to the loss of its hedonic value^9,4.

Similar to other types of addiction, individuals with FA often consume larger amounts of food than intended and experience cravings, urges, or a strong desire to eat these foods. They often report spending large amounts of time obtaining food, eating, or recovering from eating. Additionally, they mention a persistent desire for food and unsuccessful attempts to cut down on eating. They may report the necessity to eat more to reduce negative emotions or to increase pleasure, as well as withdrawal symptoms such as experiencing negative affect or physical symptoms when they stop eating. As with any addiction, FA causes clinically significant impairment and distress ^10,11.

Overweight or obesity are associated with a higher prevalence of FA than healthy weight individuals^{12, 13, 14}. A meta-analysis using studies with clinical and community samples across the lifespan has shown that the overall prevalence of FA is 20%, with 24% of individuals in the overweight BMI range and 28% in the obese BMI range meeting FA criteria¹⁵.

The tendency to overeat can be caused by the availability of attractive food, but what must be taken into account are the individual features of the person. These include temperamental traits like impulsiveness or negative urgency¹⁶, unhealthy eating habits, inefficient emotional regulatory mechanisms¹⁷, and physiological mechanisms, mostly connected with appetite-increasing/inhibiting neurotransmitters¹⁸ .

Overeating may vary in the severity of symptoms and the degree of compulsiveness. Davis⁴ (2013) proposed a continuous spectrum of eating difficulties. At one end of the continuum, there is passive overeating with no clinical consequences, then binging without clinical significance, intermittent binge eating (with all BED symptoms), and at the other end - those who meet the proposed criteria for FA based on the Yale Food Addiction Scale (YFAS)¹⁹, with higher severity of BED symptoms. Davies⁴ proposed that they express significantly more severe and compulsive symptomatology and psychopathological characteristics. In particular, they are highly impulsive, manifest significant mood disturbances, and display emotionally driven bouts of overeating. It may be seen as a food addiction phenomenon – with nearly all symptoms of FA present in BED patients but in higher severity.

The concept of FA has been based on the criteria of Substance Use Disorder, yet previously mentioned studies suggest a relationship between FA and EDs, while little is known about its extent or role. Binge eating disorder is theoretically the closest construct to that of food addiction. To check if FA might be better understood as severe BE and if it differs from other ED patterns⁴, further research is needed.

Previously, Giacomo et al.²⁰ concluded that FA can be present in subjects with obesity but without any eating disorder, as well as in subjects from the general population without any psychiatric issues. Even though the prevalence of FA in those people is sensibly lower, its presence may point towards FA being a different, separate entity from other specific EDs. Furthermore, some studies suggest that there is an overlap between BED and FA, although the exact nature of this overlap remains unclear. Individuals prone to BE may consume more food than planned and experience intense cravings for food⁸. A meta-analysis conducted by Bao et al.²² found a small yet significant positive association between FA and BMI, as well as significant associations between FA, objective BE and ED psychopathology. Despite studies showing the overlap of FA and BED in obese individuals²³ there is little research on FA and BED combined symptoms. The prevalence of FA ranges from 42–57% in populations with BED, further demonstrating the differences between the two constructs²⁰.The presence of an addictive component in some subjects affected by ED might influence their treatments and outcomes if not rightly addressed.

A study by Gearhardt et al.¹¹ demonstrated that compared to patients with BED alone, those with both BED and FA exhibited significantly higher levels of low self-esteem, depression, negative affect, and emotional dysregulation, while showing no significant differences in dietary moderation. Furthermore constructs such as emotional or restrictive eating, stress reactions, emotional functioning, and negative urgency may prove crucial for the relationship between BE spectrum symptoms (BE and FA) as they might differentiate the FA from BED. From this point of view, it may be beneficial to direct psychological interventions toward the common features but adjust the intensity of the intervention. BED, as well as other EDs, is related to increased negative emotional eating and decreased happiness obtained from eating²⁴ Under stress, individuals with a BED diagnosis tend to eat more than healthy controls²⁵. According to a meta-analysis of cross-sectional studies, there are generally positive, moderate associations between FA, BED, depression, and anxiety²⁶. FA appears to have a prominent relationship with anxiety²⁷.

A possible explanation may be found in the role of the early-life stressors (or traumatic events), and various dietary differences that arise from these stressors are influential in the susceptibility to compulsive intake of palatable foods²⁸. PTSD appears to be related to ED symptoms, FA, emotion suppression, and cognitive distortions^{29, 30}. The relationship between adverse childhood experiences and BED is often mediated by other variables such as intolerance of uncertainty and emotional regulation difficulties³¹. Everyday life stress also plays a crucial role in maladaptive food intake. Lastly, negative urgency has consistently been linked to dysregulated eating behavior^{32, 33}, especially BE³⁴ and FA ^{35, 36}.

It is believed that individuals with BE, FA, and the co-occurrence of FA and BE may exhibit variations in psychological functioning, leading to different responses to interventions that are not tailored to their specific disordered eating patterns. The ongoing debate on whether binge eating can be considered food addiction or if food addiction is a subtype of BED remains an area of active research. The distinct differences between BED and FA are not as well understood, underscoring the importance of characterizing these constructs to better assist patients in receiving appropriate treatment.

CURRENT STUDY

The aim of the current study was to compare the psychological characteristics of individuals without self-reported eating pathology (control group) to those with food addiction (FA group), binge eating disorder (BE group), and a combined FA and BED phenotype (double diagnosis group) in a non-clinical sample of Polish adults. Specifically, groups were compared on BMI, eating-related variables (including restrained eating and emotional eating), internalizing symptoms (specifically depression and anxiety severity), stress-related variables (stress severity, PTSD symptoms, adverse childhood events, and the number of traumatic events), and negative urgency. We also compared the groups within the ED group - i.e., FA, BED, and double diagnosis – on these psychological variables to determine whether individuals who belong to each of these groups differ in the severity of other psychological symptoms.

Participants and Procedure

This study is part of a larger project concerning posttraumatic stress disorder (PTSD) and food addiction. Participants between ages 18 and 55, living in Poland, were invited to complete an online survey on FA and BE, which took approximately 30 min to complete. Exclusion criteria included being pregnant/currently lactating and being unable to speak and read the Polish language. The recruitment process used various strategies: sending invitations through the university’s newsletter, the project’s social media and website, and paid advertisement in a local newspaper. Additionally, a snowball method was applied, and an external pollster company (Nationwide Research Panel Ariadna; https://panelariadna.pl/) was employed. Participants could fill in the questionnaire either on an online platform LimeSurvey or through the pollster’s company platform. A monetary compensation using a lottery system was offered to participants who completed the survey using LimeSurvey. The participants who used the pollster’s company platform collected points for completing the survey that could be exchanged for prizes. Informed consent was obtained from all subjects before taking the survey. This study was approved by The University of Silesia Ethics Committee (document of approval number: KEUS 245/04.2022).

Measures

Outcome variables

The Yale Food Addiction Scale (YFAS 2.0^{19, 37}) is a 35-item self-report measure that allows to assess eleven symptoms of food addiction experienced over the last 12 months. The YFAS 2.0 asks participants to think of specific foods, such as highly processed foods; however, participants in this study were asked to consider all foods. Participants respond using a scale from 0 “Never” to 7 “Every day”. The total YFAS score was computed as a symptom count ranging from 0 to 11. When more than two symptoms are endorsed that cause a clinically significant impairment a “diagnosis” of FA can be made. In the current study, the internal consistency was α = .95.

Binge Eating Scale (BES³⁸, Polish translation by Różycka, unpublished) is a 16-item questionnaire used to assess binge eating behavior. Each question requires choosing from three to four possible responses, reflecting a range of severity of binge eating behaviors. Participants were shown questions related to BE after they answered “Yes” to the question concerning experiencing subjective binge eating episodes. Each of the responses is weighted, with the total score being a sum ranging from 0 to 46. Participants with scores above 17 are classified as having a problem with BE. The questionnaire was translated two-way by a fluent native speaker, and the consistency in the current study was 𝛼 = .86.

Participants who scored above the cut-off point for both the YFAS and BES scales were sorted into the double diagnosis group.

Internalizing symptoms

Depression, Anxiety and Stress Scale – 21 items (DASS-21^{39, 40}) is a 21-item questionnaire that assesses depression, anxiety, and stress symptoms over the prior week. Participants answer using a 4-point Likert scale ranging from 0 “Did not apply to me at all” to 3 „Applied to me very much, or most of the time”. The scores for each subscale are obtained by summing corresponding items, with results ranging from 0 to 21. In the current study, the Cronbach’s alpha for this tool was α = .92 for Stress, α = .87 for Anxiety, and α = .93 for Depression.

Eating-related variables

Restrained Eating and Emotional Eating are subscales from the Dutch Eating Behaviour Questionnaire (DEBQ^{41, 42}) that assess participants' eating behaviors. Emotional Eating consists of 13 items concerning eating as a response to emotional states, while Restrained Eating comprises 10 items concerned with eating smaller amounts of food than wanted. Participants rate their experiences on a 5-point Likert scale ranging from 1 “Never” to 5 “Very often”. For each subscale, a score is calculated as a mean of the corresponding items. In the current study, the Cronbach alpha for Restrained Eating was α = .93 and for Emotional Eating α = .97.

Body mass index (BMI) is a person’s weight in kilograms divided by the square of height in meters. In the current study, we relied on self-reported measures of weight and height of participants.

Stress-related variables

Adverse Childhood Experiences Scale (ACE⁴³) consists of 10 items concerning exposure to trauma during childhood/adolescence. Respondents provide 1 “Yes” or 0 “No” responses, which are summed to form the “ACE” Score ranging from 0 to 10. A professional translator translated this questionnaire into Polish.

The PTSD Checklist for DSM-5 (PCL-5^{44, 45}) is a 20-item self-report measure of the DSM-5 symptoms of PTSD. The respondents rate the items on a 5-point Likert scale ranging from 0 “not at all” to 4 “Extremely”. The total score is calculated as a sum of all the items, ranging from 0 to 80. In the current study, the Cronbach alpha for PCL-5 was α = .96.

The Life Events Checklist (LEC-5^{46, 47}) is used to assess individuals’ exposure to traumatic events according to DSM-IV criteria. Respondents rate their experience on a multiple-choice, nominal scale (1 “Happened to me”, 2 “Witnessed it”, 3 “Learned about it”, 4 “Not sure”, 5 “Doesn’t apply”). The LEC score is calculated as the number of events experienced and witnessed by participants⁴⁸ (Brewerton et al., 2020), with the score ranging from 0 to 32.

Impulsivity

Negative urgency is a subscale of The Short Impulsive Behaviour Scale (SUPPS-P^{49, 50}) that assesses acting impulsively under the influence of negative affect. The subscale consists of 4 items, which participants rate on a 5-point Likert scale ranging from 0 “I totally agree” to 4 “I totally disagree. The final score for the subscale ranges from 0 to 16, with higher scores indicating higher intensity of the negative urgency. In the current study, the internal consistency was α = .82.

Data analysis

Data was coded and analyzed using IBM SPSS software. As the normality assumption was violated for all of the study variables, non-parametric tests were used. First, we analyzed the relationship between the variables using Spearman’s correlation. Then, to explore differences between the control group and the Eating disorder group (those who had either FA, BED, or both ‘diagnoses’), we used the Mann-Whitney’s test. To evaluate the differences between the FA, BED, and double diagnosis groups Kruskal-Wallis test was carried out with posthoc tests used to check differences between particular groups. We applied the Bonferroni correction to adjust for multiple comparisons.

Sample characteristics

The final sample comprised 2123 participants who completed the study, among whom 492 individuals met the criteria for either FA, BE, or both diagnoses (based on YFAS or BES score; see: Measures). There were n = 182 (8.57%) persons with FA, n = 148 (6.97%) with BE, and n = 162 (7.63%) with both disorders. A comparison group without a food disorder diagnosis consisted of n = 1631 (76.83%) participants. The final sample characteristics are shown in Table 1. The majority of the participants were female (58.9%), with a mean age of 22.06 (SD = 16.60). Most of the sample had higher education and a full-time job.

Table 1

Sociodemographic characteristics of the sample
Sociodemographic variable	Study sample (n = 2123)
Gender
Male	41.00%
Female	58.32%
Other	0.68%
Age
18–24 years of age	21.15%
25–34 years of age	24.31%
35–44 years of age	21.81%
45–55 years of age	32.74%
Education
Primary	1.7%
Vocational	7.2%
Secondary	37.15%
Tertiary	53.69%
Employment
Unemployed	9.69%
Student	19.48%
Employed full-time	56.22%
Employed part-time	7.75%
Marital status
Single	43.92%
Married	38.70%
Divorced	5.55%
In cohabitation	11.32%
In separation	0.54%
Income
Under 2000 PLN	8.30%
Between 2001 and 3500 PLN	14.43%
Between 3501 and 6000 PLN	27.19%
Between 6001 and 8000 PLN	19.43%
Between 8001 and 10 000 PLN	14.65%
Above 10 000 PLN	16.00%
Place of residence
Countryside	19.43%
Small town (less than 50.000 citizens)	18.21%
Middle-sized town (between 50 000 and 150 000 citizens)	21.60%
City (between 150.000 and 500 000 citizens)	32.82%
Big city (above 500 000 citizens)	7.93%

Table 1 Sociodemographic characteristics of the sample

The health status of participants is presented in Table 2. The mean of the BMI was equal to 25.97 (SD = 5.70, Min = 14.87, Max = 75.69). The majority of the sample reported having at least one psychiatric diagnosis and not participating in psychotherapy. Among the most prevalent diagnoses were mood disorders, anxiety disorders, hypertension, and obesity.

Table 2

Health status of participants
Health variable	Study sample (n = 2123)
Smoking
No	61.33%
Yes	27.41%
Not smoking for a month	11.26%
Somatic diseases
Hypertension	15.87%
Diabetes type II	4.19%
Insulin resistance	5.51%
Digestive system diseases	6.31%
Anemia	3.67%
Obesity	12.01%
Hypothyroidism	1.74%
Hyperthyroidism	9.14%
Autoimmune diseases	2.5%
No diagnosis	52.38%
Current psychotherapy attendance
Yes	10.17%
Psychiatric diagnoses
Mood disorders	13.00%
Anxiety disorders	13.37%
Eating disorders	4.38%
Stress-related disorders	13.09%
Psychotic	2.17%
No diagnosis	72.96%
Medications
Drugs for mood	13.61%
Supplements	34.86%
Hypertension	13.05%
Diabetes	5.18%
No medications	39.42%

Table 2 Health status of participants

Correlation between study variables

We analyzed the relationship between the study variables using Spearman’s correlation. The results are presented in Table A (see the Supplementary Materials). YFAS score has shown a positive moderate relationship with BES score, emotional eating, depression, anxiety, stress, and PCL score. On the other hand, BES scores had a moderate positive relationship only with emotional eating. Both YFAS and BES scores had a weak positive relationship with BMI.

Group comparison – ED and the control group

Descriptive statistics of the variables of interest and the results of the U Mann-Whitney test for the control group and ED group are shown in Table 3. There were differences in the YFAS score, BES score, BMI, negative urgency, restrained eating, emotional eating, depression, anxiety, stress, negative urgency, ACE, PCL, and LEC scores. For all those scales, participants with at least one eating disorder achieved significantly higher scores.

Table 3

Descriptive statistics of the study variables
	Control group Mean (SD)	ED Group Mean (SD)	Min	Max	U
YFAS score	1.34 (2.20)	6.89 (3.11)	0.00	11.00	67092.50.00***
BES score	1.43 (4.02)	17.02 (11.23)	0.00	46.00	114808.50***
BMI	25.51 (5.26)	27.48 (6.77)	14.87	62.24	331720.50***
Restrained Eating (DEBQ)	2.50 (0.84)	3.01 (0.79)	1.00	5.00	266641.00***
Emotional Eating (DEBQ)	1.99 (0.85)	3.30 (0.92)	1.00	5.00	124120.50***
Depression (DASS-21)	6.07 (5.39)	10.92 (5.42)	0.00	21.00	207610.50***
Anxiety (DASS-21)	4.66 (4.66)	9.07 (5.05)	0.00	21.00	201362.50***
Stress (DASS-21)	6.68 (5.10)	11.58 (4.82)	0.00	21.00	191156.00***
ACE	1.03 (1.51)	1.88 (1.83)	0.00	10.00	275653.00***
PCL-5	25.34 (18.25)	43.31 (16.30)	0.00	80.00	185889.50***
LEC	5.77 (6.21)	9.66 (8.30)	0.00	51.00	281180.50***
Negative urgency	9.80 (2.60)	11.21 (2.71)	4.00	16.00	281281.00***
Note. YFAS score = Yale Food Addiction Scale number of symptoms; BES = Binge Eating Scale; BMI = Body Mass Index; ACE = Adverse Childhood Experiences Scale; PCL-5 = The PTSD Symptom Checklist for DSM-5; LEC = The Life Events Checklist;
***p < .001.

Table 3 Descriptive statistics of the study variables

Group comparison – FA, BE and double diagnosis

People with a double diagnosis had significantly higher levels than the BE group on the YFAS scores (p < .001), BES scores (p < .001), negative urgency (p = .029), emotional eating (p < .001), restrained eating (p = .002), depression (p < .001), anxiety (p = .028), stress (p < .001), ACE (p = .039), and PCL (p < .001). Additionally, the double diagnosis group had higher scores than the FA group on YFAS score (p = .007), BES score (p < .001), negative urgency (p = .010), emotional eating (p < .001), ACE (p < .001), and LEC (p = .028). The FA group, compared to the BE group, had higher levels of the YFAS score (p < .001), anxiety (p = .0028), stress (p < .001), and PCL (p < .001). Participants in the BE group reported higher scores on the BES (p < .001) and had a higher BMI (p = .049) than the FA group. None other comparisons were significant after the Bonferroni adjustment.

Table 4. The results of the Kruskal – Wallis test for FA, BE, and double-diagnosis groups

Table 4

The results of the Kruskal – Wallis test for FA, BE, and double-diagnosis groups
	FA (1) n = 182	BE (2) n = 148	Double diagnosis (3) n = 162	H	df	p	Sig. Comparisons
	M (SD)	M (SD)	M (SD)
YFAS score	7.18 (2.88)	5.18 (3.12)	8.12 (2.64)	66.86	2	< .001	3 > 1 > 2
BES score	4.67 (6.86)	22.61 (4.15)	25.80 (6.09)	358.52	2	< .001	3 > 2 > 1
BMI	26.62 (6.42)	28.56 (7.15)	27.45 (6.70)	6.49	2	.049	2 > 1
Restrained eating	3.01 (0.83)	2.86 (0.70)	3.14 (0.80)	11.68	2	.003	3 > 2
Emotional eating	3.10 (0.93)	3.19 (0.86)	3.61 (0.87)	31.82	2	< .001	3 > 2; 3 > 1
Depression	10.85 (5.18)	9.70 (5.46)	12.13 (5.41)	14.73	2	< .001	3 > 2
Anxiety	9.43 (4.98)	7.99 (4.72)	9.66 (5.30)	8.09	2	.017	1 > 2; 3 > 2
Stress	11.70 (4.67)	10.13 (4.90)	12.78 (4.57)	20.34	2	< .001	1 > 2; 3 > 2
ACE	1.46 (1.71)	1.88 (1.77)	2.36 (1.89)	28.21	2	< .001	2 > 1; 3 > 1; 3 > 2
PCL	44.69 (16.22)	37.18 (15.61)	47.36 (15.45)	32.07	2	< .001	1 > 2; 3 > 2
LEC	8.65 (8.09)	9.87 (8.15)	10.60 (8.57)	6.80	2	.033	3 > 1
Negative urgency	10.83 (2.95)	11.01 (2.37)	11.81 (2.62)	10.83	2	.004	3 > 1; 3 > 2;
Note. YFAS score = Yale Food Addiction Scale number of symptoms; BES = Binge Eating Scale; ACE = Adverse Childhood Experiences Scale; PCL = The PTSD Checklist for DSM-5; LEC = The Life Events Checklist; Sig. Comparisons - significant comparisons;
*p < .001; p < .01; *p < .05;

The primary goals of this study were to examine the psychological correlates of food addiction (FA), binge eating (BE), and a combination of both (FA + BE) in the general population. We demonstrated that FA and BE symptoms are present in non-clinical populations at relatively high rates. As expected, compared to individuals without reported disordered eating symptoms, individuals with these symptoms demonstrated greater severity of eating difficulties (i.e., emotional eating and dietary restraint), greater BMI, more internalizing symptoms (depression, anxiety, stress), more PTSD symptoms severity in the clinical range (vs. a non-clinical range for control participants), as well as reported more lifetime traumatic events and adverse childhood events. Within the ED groups, we found that the double diagnosis group presented the most severe pattern of behavioral and emotional symptoms, followed by the FA alone group, while the BE group had the fewest symptoms. Individuals with a double diagnosis, compared to either one of the other groups, reported significantly more food addiction and binge eating symptoms, greater emotional eating, and more adverse childhood events. They also reported higher levels of restrained eating, depression, anxiety, stress, and negative urgency, as well as more severe PTSD symptoms compared to the BE group alone.

We observed that double diagnosis group had more severe symptoms than FA and BE separately. As we previously noticed, FA and BE share many common features²³. The studies by Davis et al.⁵¹ and Gearhardt et al.⁵² found that more than half of obese adults diagnosed with food addiction (based on YFAS) also met the criteria for BE. The researchers concluded that the BE-FA group was defined as a more disturbed variant of BE with higher rates of ED psychopathology, negative affect, emotional dysregulation, and low self-esteem⁵² – which is in line with our results. Our research adds one more stage to this continuum. We observed that people with FA presented more severe impairment in psychological functioning than people with high scores on the BES scale without FA. FA might represent a medium stage on the BE psychopathology continuum. It might be seen as a more disturbed type of BE, showing that binging might evolve into the constant urge to eat. These results are in line with the eating disorders continuum defined by Davis⁴ and the reward-based process model connecting negative emotional states and food addiction⁵³. We might hypothesize that the double diagnosis group presents addiction to quantity and specific types of food⁵⁴.

In BE, people experience dietary issues, concerns about weight, body shape, and depression symptoms, as well as brooding rumination. FA can be classified as substance addiction or behavioral addiction, based on criteria such as hunger, taste, pleasure, social connection loss, weight concerns, and awareness about addiction. Research showed that people with FA eat to gain hedonic pleasure, and they tend to look for their desired product, but people with BE might not activate binging without the release⁵⁴. As such, people with both diagnoses may develop mixed strategies - to gain pleasure and to improve negative mood - and it might not be clear which kind of interventions to implement to decrease ED symptoms.

We also noted that depression, emotional eating, and restrained eating were present in the double diagnosis group - FA + BE group resulted in negative affect and impaired functioning However, they were not specifically in the FA and BE groups separately. Participants with both FA and BE characteristics were more likely to overeat for emotional reasons. It has been reported that negative affect is a key feature across cognitive-behavioural theories of binge eating⁵⁵. We might say that binge eating serves as an avoidance from awareness⁵⁶ in which the salience of adverse emotions is limited through cognitive narrowing that occurs during consuming food. There has been empirical evidence that negative mood plays a significant role in binge eating⁵⁷ – as a consequence but in addition as a trigger for binging. The results are also in agreement with those of Stice et al.⁵⁸. The dietary/depressed subgroup in his research exhibited mental dietary preoccupation. It also featured increased interpersonal sensitivity, negative urgency, alexithymia, and lower emotional regulation strategies.

Compared to the non-addicted BE participants, the FA group reported more negative consequences due to their eating difficulties and had significantly elevated symptoms of anxiety and stress which is in line with previous research by Parylak et al. ⁵⁹. According to Burrows et al.²⁶, FA is a result of coping with distress through eating. It is also possible that the mechanism is also connected to compulsive addiction⁶⁰, in which depriving yourself of a compulsive habit is associated with negative emotionality, such as anxiety, as a consequence of restraining it. We might speculate that people with FA eat to regulate distress emerging from their psychological difficulties – they use eating as an avoidance strategy. The FA group also reported heightened PTSD symptoms, showing potential factors contributing to the diagnosis.

Despite the high anxiety symptoms associated with binge eating overall⁶¹, research suggests that binge eating itself is associated with reduced anxiety⁶². The higher rates of anxiety symptoms, coupled with the reduction in anxiety following binge eating, suggest a process that links these two issues. In our research, we might speculate that while BE may be more connected to depressed mood instead of anxiety, the FA group - being more anxious and stressed - implemented ineffective regulation strategies with eating becoming an urge and conditioned habit with irregular psychological rewards. This reasoning is in line with seeing FA through addiction disorders. As Shapira and Courbasson⁶³ reported, anxiety in ED predicted if patients used substances or not, while anxiety and depression predicted ED severity. FA may be seen as an initial response to high physical discomfort which is conditioned over time. Furthermore, anxiety might represent one of the symptoms of substance or behavioral addiction⁶⁴.

Participants with more food addiction symptoms had higher PTSD symptoms than the BE group. There might be an overlap in mechanisms between eating disorders and PTSD, as concluded in Meule and Gearhardt's review⁶⁵. People with PTSD have a higher prevalence of all EDs⁶⁶ especially those connected to binging67. Trottier and MacDonald⁶⁸ conclude that the potential mechanisms of the trauma-ED relationship may lie in emotional dysregulation, anger, and impulsivity/compulsivity. In Brewerton’s review⁴⁸, it was stated that experiencing ACEs may lead to self-destructive behaviors, including ED behaviors. It is probable that participants with FA symptoms exhibited a maladaptive regulation due to higher arousal or avoidance mechanisms than BE.

According to the MATEO study, FA is also associated with higher psychological distress and maladaptive eating patterns⁶⁹. Higher levels of uncontrolled and emotional eating, stress, as well as lower psychological well-being and cognitive restraint, predicted food addiction in individuals with obesity. It is important to note that diagnosing FA among binge eating patients may direct professionals towards more effective treatment – focusing on anxiety for FA, on mood for BED, or both in case of double diagnosis.

Negative urgency was pronounced in both FA groups (FA group and double diagnosis group) compared to BE alone. A few studies have also indicated a positive relationship between negative urgency and food addiction symptoms^{70, 36}. Negative urgency, defined as the disposition to act rashly when in distress, might make people more likely to seek out stress regulation strategies like eating behaviors. Most research shows a positive association between impulsivity and ED symptoms, especially those with binging episodes⁷¹. Taking into account our results, negative urgency in FA may act like an urge to consume certain foods or to the process of eating as a whole – and it is not characterized as an objective binge (i.e., having a lot of food at a certain time, often in loneliness, being planned and connected with negative mood and guilt). As Ratkovic et al.⁵⁴ concluded that FA is driven mainly by impulsivity.

The study by Wolz et al.³⁶ showed that patients who, in addition to emotional difficulties, tend to act impulsively when in negative mood states (especially anxiety), are at risk of developing addictive eating patterns. In other words, ED patients who are more prone to act impulsively in reaction to anxiety or stress might be at higher risk of developing eating patterns connected with addictive behavior.

Concluding, the anxious and stressed FA group may represent a different pattern of eating behaviors than the depressed BE group. Emotional eating, which includes snacking, taking a regular meal, or overeating, might be specific for BE due to the consumption of an unusually large amount of food but in a short period of time with a sense of loss of control. The FA construct, also connected with binge eating symptoms, might be an indicator of higher ED severity⁴.

Finally, we noted that BE group had a higher BMI than FA group. The correlation analyses (reported in the Supplementary Materials) indicated that the relationship between FA symptoms, binge eating severity, and BMI was very weak. Cernelic-Bijzak and Guine⁷² proposed that uncontrolled eating and BMI might be separate phenomena that affect one another only in certain cases. The results of this study demonstrated that adults with FA or double diagnosis may not have obesity and still report symptoms of uncontrolled eating and their consequences. We must note that compensatory behaviors were not controlled and may influence the overall weight of the participants. However, other factors contributing to uncontrolled eating and BMI should also be considered. It is possible that potential BMI-influencing factors like level of everyday spontaneous activity, type of work, dietary habits, medication use, and biological predispositions affected the relationship between disordered eating and BMI. In the group comparison, people with FA and BE in the ED group had a slightly higher average BMI than those in the control group, indicating weight gain. Due to the non-clinical character of the research sample, they may represent a risk group for future weight gain.

The FA/BE symptoms require further investigation to check the possible compensation strategies and the temporal aspect of the FA/BE symptoms (short time to gain weight due to binging or eating too much of the desired product). Excessive eating, like in BE, might be consistent with cultural and social background. People with normal weight might be less distressed and impaired by food addiction symptoms as they have personal and social acceptance of eating, as proposed by Carr et al.⁷³. Moreover, FA eating patterns are slightly different from BE eating patterns. As such there might be less high-calorie food eaten in a large amount and in a short period of time, like binging (resulting in this group with a slightly higher BMI).

On the one hand, binging episodes are the answer to dieting, eating restriction, and weight reduction. However, on the other hand, binging might have an onset before dieting⁴⁸. It may also explain our results – our participants may experience excessive food consumption as a result of emotional dysregulation or restriction of their favorite food. In spite of this, low calorie intake is not responsible for this. Another explanation might be the participants’ high weight before starting binging episodes (which is in line with the dietary restriction hypothesis as a background for binging).

LIMITATIONS

Some limitations of the present study should be mentioned. Due to the cross-sectional study design, it was impossible to investigate causal relationships between variables. Also, the online version of the research might have had an impact on the participants' responses, as external stimuli might have influenced their ability to focus on the questionnaire. Furthermore, as we only used self-reports, we did not have an objective measure of participants’ height and weight to generate measured BMI as well as access to the history of weight along with the dietary history. Moreover, not all participants filled out BES as it was an optional questionnaire for individuals who endorsed loss of control over eating. It required personal insight into the participant’s behaviors and experienced subjective distress that may not be present in all people suffering from BED. Furthermore, caloric intake and activity levels were not controlled. Those aspects are relevant in analyzing the binge behavior structure, as it is possible that some percentage of binges might be the result of excessive activity or low caloric intake during the day. Further studies should consider compensatory behaviors. Lastly, our study included a high number of women, which further limits the generalizability of the population.

This study provides further support for the operationalization of FA as BE and FA appear related but do not totally overlap. They may be often diagnosed together but due to the behavior structure and slightly different symptoms – professionals may have to match the effective treatment. Due to the differences in anxiety, stress, depression, eating habits and negative urgency, FA and BE management might require specific skills. It is worth noticing that BE has its own eating habits, in particular binging and the behaviors one undertakes towards binge planning. It may evolve in FA when situational and psychological circumstances change – possibly when anxiety arises or when addiction symptoms develop. Eating mechanisms in FA are also linked to PTSD symptoms as a way of coping with stress and emotion regulation. We propose that FA might worsen a comorbid eating disorder that does not present itself as a typical addiction with binge episodes. Instead, it may be seen as a more aggravating form of ED. As a consequence, we strongly encourage the evaluation of FA presence in patients with ED as well as in those with obesity. This will enable them to tailor their treatment with greater precision and address all the components that may influence a patient’s response to treatment and their outcomes. People with both disorders report the most difficulties in functioning. Disordered eating might not be related to higher BMI, but it might be a risk factor to develop obesity in the future.

COMPLIANCE WITH ETHICAL STANDARDS

The study was approved by the Departmental Ethics Committee. All procedures in the present study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

DATA AVAILABILITY STATEMENT

For the purpose of Open Access, the author has applied a CC-BY public copyright license to any Author Accepted Manuscripts (AAM) version arising from this submission. The datasets generated during and/or analysed during the current study are available from the co-author upon request (for. M.M.Stojek). The dataset will be stored in the repository and will be publicly available by December 31, 2024.

Author contribution statement

JR conceived and designed the study, wrote Introduction and Discussion; AN analysed the results, wrote the Data Analysis, Method and Results sections; MMS, MŁ, MS and RD participated in study design and data collection. MMS and MŁ edited and reviewed the last version. All authors reviewed the manuscript.

Additional information

The authors declare no competing interests.

The study was supported by the National Science Centre, Poland (OPUS 21, grant no. 2021/41/B/HS6/04029; PI: Monika M. Stojek).

The research activities were co-financed by the funds granted under the Research Excellence Initiative of the University of Silesia in Katowice to Monika M. Stojek.

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No competing interests reported.

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Psychological differences in food addiction and binge eating in non-clinical population

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Abstract

INTRODUCTION

CURRENT STUDY

METHODS

Participants and Procedure

Measures

Outcome variables

Internalizing symptoms

Eating-related variables

Stress-related variables

Impulsivity

Data analysis

RESULTS

Sample characteristics

Correlation between study variables

Group comparison – ED and the control group

Group comparison – FA, BE and double diagnosis

DISCUSSION

LIMITATIONS

CONCLUSIONS

Declarations

References

Additional Declarations

Supplementary Files

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