19th March 2010, Volume 123 Number 1311

Ria Schroder, Doug Sellman, Jane Elmslie

Addictive overeating can be conceived as an ego-dystonic compulsion to overeat, despite the person recognising the harm it is causing, similar to the compulsion to use drugs in drug addiction.1 An increasing body of evidence now exists to suggest that highly pleasurable foods (particularly those high in sugars, salt and fats) have the potential to initiate compulsive behaviour which can result in a clinical state of addictive overeating.1–7

While the availability of energy dense fast foods and the cost differential between ‘healthy foods’ and ‘junk foods’ are clearly established risk factors for the development of obesity, there remains considerable scepticism about the possibility that some people might be “addicted to food”. The terms “food addiction” and “addictive overeating” are viewed by many as convenient excuses for excessive food intake and clinicians rarely consider the role that addictive overeating may have in the development of overweight and obesity.

In contrast, drug addiction and other associated compulsive behavioural disorders such as pathological gambling are recognised as mental disorders that can severely impact the lives of the addicted person, their family and friends. Consequently, advances have been made in research and clinical intervention to assist people to recover from these addictions. To date, however, this same perspective has not been applied to addictive overeating. In a climate where disbelief and negative stereotypes have dominated, little information exists that portrays the lived experiences of people who have problems with controlling their food intake.

One forum, however, that has been committed to hearing about the lived experiences of overeaters worldwide is Overeaters Anonymous (OA). OA is a self-help group for compulsive overeaters and follows the same 12 Step principles as Alcoholics Anonymous. Members of OA consider compulsive eating to be a threefold disease comprising physical, emotional and spiritual components that can be arrested through abstinence from compulsive eating, but cannot be cured.8,9

Regardless of whether or not one subscribes to the particular theoretical model that underlies OA, it is clear that OA has provided a forum for overeaters to meet for support and to feel safe to share their stories. OA has also provided a forum in which clinicians and researchers are able to learn more about overeating by hearing the experiences of people who identify as overeaters. To date however, the lessons that have been learned about overeating from OA have been mostly restricted to those people who have had direct contact with OA and its members.

The aim of this paper is to examine this collective experience through the lens of a group of fifth-year medical students who had attended an OA meeting as part of their course requirements. A systematic analysis involving a qualitative research method was used to analyse the students’ observations about people’s experiences of food addiction and the impact this addiction can have on individuals’ daily lives.

Method

Background—As part of the course requirements for the Addiction Medicine component of their training, all fifth-year medical students at the University of Otago Christchurch are required to attend one self-help group meeting and to write a report about this experience. The data presented in this paper are extracts from reports written by the fifth-year medical students in 2002–2007 who attended an OA meeting. Over this period 72 (19.5%) out of a total of 370 students chose to attend an OA meeting. Of the remaining 298 students, 214 (57.8%) attended Alcoholics Anonymous (AA), 44 (11.9%) Narcotics Anonymous (NA), 27 (7.3%) Gamblers Anonymous (GA), 10 (2.7%) AL-ANON and three (0.8%) Rational Recovery.
In 2007 permission was given by the University of Otago Student Body to use the submitted reports to conduct a thematic analysis. The anonymity of all students was maintained by removing all student names and identifying details from the reports prior to analysis.
Representatives from OA who had been involved in teaching the students and facilitating their access to the OA groups also gave permission for the student reports to be analysed and for this paper to be written.
Procedures—All reports were read and initially coded by RS, who is not involved in the teaching or examination of the Addiction Medicine course. Thematic analysis is a qualitative method of analysis which requires in-depth examination of the data to allow common themes to emerge.10 Initial coding revealed a number of minor categories that were summarised into preliminary themes. After further analysis the preliminary themes were condensed into the three major themes discussed in this paper. Independent rating was achieved by the second author comprehensively reading all reports and providing feedback on initial and final themes.
Participants—Of the 72 students, 53 were female (73.6%). A stable interest in attending OA remained across the years with nine students attending in 2002, 14 in 2003, 12 in 2004, 13 in 2005, 12 in 2006 and 11 in 2007.

Results

Three main themes emerged from the analysis: ‘Conceptualising Food as Addictive’, ‘The Experience of Being Addicted to Food’ and ‘Impact on Education and Practice.’ Each theme is discussed in turn below.

Conceptualising food as addictive—For the most part, the concept of food as a substance to which people can become addicted, is only beginning to be more widely considered and researched. Given this context it was not surprising that most of the medical students who attended OA initially did so because of their uncertainty about the concept of food as an addictive substance.

For many this was revealed as their failure to have ever contemplated food as a potentially addictive substance.

I had no idea that people could be addicted to food, and not only to nice food, but just any food (frozen, out of the rubbish bins). It also seemed to me that all of the other groups work towards abstinence, but food is something that is essential to our lives, so I was curious as to how people could recover from the addiction, and eat ‘normal’ again. Female, 2007

Lack of familiarity with the concept of addictive overeating was also discussed by OA members as they shared their experiences. Many commented on the lack of understanding they had of the disease they now term addictive overeating.

...she thought she couldn’t possibly be as “weak-willed as an alcoholic,” having thought that someone with alcohol dependence should obviously just stop and it would solve all their problems. That was before she realized that she had the same problem with food. Female, 2007

Others indicated how they perceived that other people such as health professionals also lacked this knowledge.

Most of the participants had seen multiple professionals and attempted many therapies (GP’s, psychiatrists, religions, group therapy, alternative therapies and endless diets) to try to work out what was wrong with them. Female, 2003

Lack of knowledge of addictive overeating was also reflected in the students’ surprise about the types of people who attended OA. Over 60% of students reported that the people who attended OA meetings were not who they had expected. Most had expected to see overweight, middle aged females and were greatly surprised when they attended groups of mixed gender, mixed weight ranges (mainly comprising normal weight rather than overweight people) and mixed age ranges. Students were also surprised at the large numbers and the length of time many members had been attending groups. Some members reported OA attendance in excess of 20 years.

The experience of being addicted to food—The stories that OA members told about their lives and their relationships with food prior to OA depicted the features of salience, dyscontrol, compulsive use and tolerance associated with addiction.

In contrast to most other addictions, OA members described their addiction to food as something that began at a very young age with many recalling problems with overeating in childhood. For some, their eating behaviour became a major focus of others’ attention and intervention was sought very early on in life.

...She had always had a problem with food and her mother had told her as a little girl that she wished she would eat “normally”. ...Originally her mother tried to prevent her. However eventually she decided that if she got sick enough it might cure her. Female, 2004

For others, it was something they had simply grown up with and it was not until later in life that they realised their thoughts about food and their eating behaviour were different.

...several people shared that their problem started at a very young age and that for a long time they did not realise that other people “weren’t obsessed with food 24/7” and weren’t overeating like they were. Female, 2007

The power of food in OA members’ lives became apparent as they described their overwhelming desire to eat food.

“...I could not stop. I would eat everything, Tim Tams, ice cream, frozen food, food covered in ants, food from the rubbish bin. At least I didn’t eat the food from the street, I wasn’t that bad.” OA participant as quoted by female student, 2005

The salience of these desires was seen by OA members as extremely oppressive.

They talked about how their obsessions were very disturbing for them, often present from the moment they woke up until they went to bed. The only way to relieve the thoughts would be to eat and continue eating at every possible moment. In order to satisfy their obsession some of the women stole food or money or had no concern for what they ate, admitting to eating cat food or eating out of rubbish bins. Female, 2002

Attempts to control this obsession were common and it was not unusual for extreme measures to be taken in an attempt to prevent overeating.

People described in detail how their lives were totally consumed by eating: “every hour of every day” said one lady. Another talked of how she had to spray her garbage bag with Spray n’ Wipe so that she would not sneak out and eat secretly. Male, 2004

Alongside attempts to control eating, came stories of the lengths that people would go to obtain food.

At boarding school she told how she would steal food from fellow students and risk punishment for sneaking food into her dormitory. ...The stealing and obsessive behaviour continued into her adult life... ... the breaking point came when she found herself trapped in her room lying in a food-smeared bed wanting to die. Female, 2004

The consuming nature of addiction was also evident from the extreme distress OA members experienced.

One particular quote struck me, “Overeating is a career...in that you career all over the place”. ...Several people mentioned the desperation and anguish to the level where they even considered suicide. Male, 2005

Negative emotional reactions sparked yet more problems as many described how they were both an antecedent to and a consequence of overeating.

Many spoke of the shame and embarrassment associated with overeating. A common theme was related to the cyclical nature of the disease, after a binge people always felt as if that would be the last time, that they would not let this happen again, and then when it did happen again, they would feel even worse and the cycle would continue. Female, 2006

Many OA members also indicated that the area of their lives that was most commonly affected was their relationships with significant others.

...for many years he concealed his problem with food from his friends and family and refused to admit it to himself. This pattern of behaviour caused him to isolate himself more and more from his friends and family. Male, 2006 ... there were many, many ruined relationships represented at overeaters anonymous (OA). Male, 2003
One lady talked about strained relationships with her children, and how she ‘neglected’ her daughter because all she wanted to do at night was to climb into bed early and just eat for the rest of the evening. Female, 2004

Similar to other addictions, OA members also described comorbid addictions to other substances either as a co-existing addiction or as a replacement addiction. In addition members described the many attempts they had made to stop their overeating.

Listening to the individual stories I found that this addiction was astoundingly similar to alcohol and other drug addictions. These people were completely powerless over food. ...But like in other addictions people commonly had to hit rock bottom before turning around or seeing the light. Female, 2007

Impact on education and practice—Many of the students commented on the value of attending OA and expressed how it had been enlightening and had served as a valuable learning experience.

...it would be one of the most powerful experiences I have had within the med school. As a result I believe that now, through having had this experience, I would be able to advise patients who have an addiction about the appropriate paths they should take. Female, 2003 To be honest, it was something that showed me more of the human side of addictions and gave a glimpse of broken lives that no amount of theory-based learning can adequately convey. Female, 2004

Furthermore, the potential long term benefits were highlighted in the students’ reflections about what this experience would mean for their future practice as medical professionals.

I think attending this self help group was not only beneficial for me understanding addiction, but also providing me with information for overeaters and people who have problems with food to not be too scared in opening a subject I was not comfortable with before, to ask them about it and inquire into it.... Female, 2003

Discussion

To conceive that something as fundamental to human survival as food has the potential to trigger compulsive behaviour that impacts severely on an individual’s health and well being is somewhat counterintuitive. “Addictive overeaters” themselves appear to struggle to understand what is happening for them and this appears to be mirrored in the slow evolution of research on overeating from an addiction perspective.

The purpose of this study was to view OA through the eyes of a group of 72 fifth-year medical students. We found that a general lack of awareness existed among medical students and consumers alike about the concept of addictive overeating or addiction to food prior to attending OA. These findings also suggest that ignorance about addictive overeating extends far beyond the participants in the present study as OA members reported that they experienced a lack of understanding from other health professionals, their own friends and families and society in general. A failure to entertain the possibility that such a condition exists is further reiterated in the research literature where the concepts of food addiction and addictive overeating have only recently begun to be more widely discussed and researched.1,4

Hearing the narratives of the OA members’ experiences with food, weight gain and compulsive eating appears to have enabled the medical students to move beyond their own experiences and begin to appreciate the serious implications of addictive overeating for sufferers. Similarly OA members recalled their own growing acceptance and understanding of their eating behaviours through their participation at OA.

The destructive and all-consuming nature of compulsive eating is evident from these discussions and from a qualitative perspective at least, appears to strongly resemble other substance and behavioural addictions. Our findings are in agreement with early findings in the quantitative literature that suggest a strong similarity between food and other substance addictions, including the compulsive nature of consumption and associated negative life consequences.1-7

The students’ accounts of the real life experiences of people living with a compulsion to overeat highlight how a willingness to listen can benefit both clinicians and patients and may help to bridge the gap between the theoretical construct of addictive overeating and effective treatment. Their resounding positive feedback about attending an OA meeting makes clear both their increased understanding of addictive overeating and their confidence in assisting patients presenting with such a disorder.

These results suggest that exposure to the lived experiences of people with addictive overeating may help doctors to be more compassionate and confident in their dealings with patients who overeat, to the benefit of both parties. In fact medical students, and students training in other health disciplines, may benefit greatly from the opportunity to interact with potential client groups in a non clinical setting.

Removing the onus on students to provide a solution for patients’ problems and allowing them to just listen and learn about the reality of living with a particular disorder is likely to provide them with a different viewpoint on which to base their practice. This method of teaching is not only appropriate for students in training but may also be useful for ongoing professional development with qualified practitioners.

Finally, the results suggest that at least for some people, abstinence from problem food(s) may be a more effective therapeutic strategy than the more widely promoted principle of moderation encouraged by both mainstream health providers and commercial weight loss companies. Controlled studies comparing these different approaches are clearly required.

Summary

Obesity is a serious and debilitating medical condition which can impair both physical and psychological health. Addictive behaviours, especially tobacco smoking and compulsive alcohol use are accepted as important causes of ill health in modern society. To conceive that something as fundamental to human survival as food has the potential to trigger compulsive behaviour that may seriously compromise health and wellbeing is perhaps counterintuitive. This study viewed the concept of ‘addictive overeating’ through the eyes of a group of fifth-year medical students who attended Overeaters Anonymous meetings as part of their course requirements. The study findings highlight the value of developing empathy in trainee doctors towards patients with obesity and suggest that exposure to groups such as Overeaters Anonymous during training may better equip doctors and other health professionals to become more therapeutically effective with this major health problem.

Abstract

Aim

To explore medical students’ perceptions of Overeaters Anonymous (OA).

Method

72 fifth-year medical students’ reports of their experiences of attending OA meetings were analysed using thematic analysis. Students were required to submit these reports in order to complete a compulsory component of the Addiction Medicine run in their medical training at the University of Otago, Christchurch during 2002–2007.

Results

Analysis of the students’ reports highlights an emerging understanding of the concepts of addiction in general and addictive overeating in particular. This understanding is reflected in the students’ acceptance of addictive overeating as a potential disorder and their increased empathy and confidence in working with patients with this disorder.

Conclusion

Improving treatment for people with obesity is a major contemporary health challenge. Addictive overeating could be a critical element in understanding the nature of obesity but has not been the subject of extensive research to date. Medical students in this study discovered that addiction to food is not just a theoretical construct but fits with the actual experience of people. The poignancy of these narratives illustrates how such information can promote greater understanding of medical and other life issues which may benefit their identification and treatment.

Author Information

Ria Schroder, Research Fellow, National Addiction Centre, Department of Psychological Medicine, University of Otago, Christchurch; Doug Sellman, Professor of Psychiatry and Addiction Medicine and Director National Addiction Centre, Department of Psychological Medicine, University of Otago, Christchurch; Jane Elmslie, Research Fellow and New Zealand Registered Dietitian, National Addiction Centre, Department of Psychological Medicine, University of Otago, Christchurch

Acknowledgements

The authors thank the Student Body of the University of Otago, Christchurch and the Christchurch fellowships of Overeaters Anonymous for their support of this research.

Correspondence

Dr Ria Schroder, Research Fellow, National Addiction Centre, University of Otago, Christchurch, PO Box 4345, Christchurch Mail Centre, Christchurch 8140, New Zealand. Fax. +64 (0)3 364122

Correspondence Email

ria.schroder@otago.ac.nz

Competing Interests

None known.

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