**About the Editors**

**Stephanie Cassin** is an Associate Professor of Psychology and Director of the Healthy Eating and Lifestyle (HEAL) Lab at Ryerson University. She also holds a faculty appointment in the Department of Psychiatry at the University of Toronto. Prior to working in academia, she was a staff clinical psychologist in the Bariatric Surgery Program at Toronto Western Hospital. She has expertise in psychosocial interventions for binge eating and obesity. Her research focuses primarily on psychosocial predictors of bariatric (weight loss) surgery outcomes, and psychosocial interventions with the potential to improve outcomes, including cognitive behavioural therapy and motivational interviewing. She also investigates health care innovations that increase treatment accessibility, such as virtual interventions. Dr. Cassin has developed treatment manuals for a number of clinical trials and has published her research widely in peer-reviewed scholarly journals. She is the co-editor of the book *Psychological Care in Severe Obesity: A Practical and Integrated Approach* and regularly trains health care professionals in evidence-based psychosocial interventions for disordered eating and obesity.

**Sanjeev Sockalingam** is a Professor of Psychiatry at the University of Toronto and the Director of the Bariatric Surgery Psychosocial Program at the Toronto Western Hospital, University Health Network. He is a Clinician Scientist and Vice President of Education at the Centre for Addiction and Mental Health. He is Vice-Chair, Education for Psychiatry at the University of Toronto. He is also the Co-Chair of ECHO Ontario Mental Health, which is a provincial hub-and-spoke knowledge network. Dr. Sockalingam has >190 peer-reviewed publications and is co-editor of the book *Psychiatric Care in Severe Obesity*, a comprehensive summary of an integrated approach to the assessment and managing psychosocial care in severe obesity, and a newly released book by Cambridge University Press, *Psychological Care in Severe Obesity: A Practical Approach*. He has funding from CIHR and other peer-reviewed agencies examining psychosocial outcomes related to obesity care, psychological treatments for obesity, and exploring the construct of food addiction. He is the co-principal investigator on a large multi-site CIHR funded study to evaluate the long-term outcomes of telephone-based cognitive behavioural therapy after bariatric surgery. Dr. Sockalingam is a co-author on the 2020 Canadian Obesity Guidelines.

## *Editorial* **Advances and Future Directions in the Clinical Utility of Food Addiction**

**Stephanie E. Cassin 1,2,3,\* and Sanjeev Sockalingam 2,3,4,5,\***


The body of research examining the validity of food addiction and eating addiction far exceeds the research examining their clinical utility. Although neither food addiction nor eating addiction are officially recognized diagnoses, many individuals self-identify as "food addicts" and/or exceed the cut-offs on measures of addictive-like eating. To be clinically useful, a diagnosis should inform the treatment plan and predict clinical outcomes. This special issue presents a collection of articles, contributed by renowned experts, researchers, and clinicians spanning different disciplines, that adds to the knowledge on the clinical utility of food addiction and eating addiction. The articles in this collection include reviews [1–5] as well as original research utilizing a variety of methodologies and study designs such as clinical trials [6–8], cross-sectional studies [9,10], and surveys [11].

Oliveria et al. [10] examined the characteristics of individuals seeking treatment for food addiction and found that they were very likely to present with comorbid diagnoses (83% of patients). On average, patients presented with 2 to 3 comorbid conditions, with anxiety and mood disorders being the most common. They also reported impairment in psychological, physical, and social functioning, and food addiction was a significant predictor of social impairment even when controlling for binge eating, depression, and anxiety severity.

In their international survey of health care professionals who potentially work with patients presenting with addictive eating behaviour (e.g., dietitians, psychologists), Burrows et al. [11] reported that the majority of respondents had been asked about addictive eating before (72%) and were interested or very interested in receiving training regarding addictive eating. They specifically reported a need for training in assessment/diagnosis (77%) and evidence-based treatments (81%). Therefore, knowledge translation of and training in food addiction assessment and treatment is needed to build capacity amongst healthcare providers.

Wiss & Brewerton [3] contributed a helpful guide to this special issue that can assist with the assessment of food addiction and differential diagnosis. Specifically, they described a comprehensive approach for assessing food addiction that takes into consideration factors such as dietary restraint and comorbid psychiatric disorders. By helping to distinguish food addiction from other forms of eating pathology, this approach aims to guide case formulation and treatment planning. Importantly, the authors concluded that "one size will not fit all in food addiction treatment" (p. 17).

A number of authors contributed papers to this special issue that emphasize the need for individual-level and societal-level interventions for food addiction. In a sample of post-operative bariatric surgery patients, Cassin et al. [6] found that those with food addiction reported greater binge eating characteristics and psychiatric distress relative to those without, and there was preliminary evidence that a brief telephone-based cognitive

**Citation:** Cassin, S.E.; Sockalingam, S. Advances and Future Directions in the Clinical Utility of Food Addiction. *Nutrients* **2021**, *13*, 708. https:// doi.org/10.3390/nu13020708

Received: 9 February 2021 Accepted: 19 February 2021 Published: 23 February 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

behavioural therapy intervention may lead to short-term improvement in food addiction symptoms. Two other studies examined food addiction in the context of behavioural weight loss programs. In a sample of individuals with obesity and binge eating disorder participating in a behavioural weight loss program, Wiedemann et al. [7] found that those with food addiction reported a stronger negative reaction to weekly weighing and less acceptance of their weight and shape throughout treatment, and the authors recommended that body image concerns be targeted in treatment given that both of these factors prospectively predicted greater eating disorder psychopathology. Gordon et al. [8] found that food addiction symptoms improved during a behavioural weight loss program; however, more severe food addiction symptomatology was associated with less weight loss. Interestingly, reduced intake of hyperpalatable foods during the program was associated with short-term improvements in food addiction symptoms but not with long-term improvements in food addiction symptoms or weight, suggesting that the association among hyperpalatable foods, food addiction, and weight is a complex one.

In his review and commentary, Lustig [1] provides a compelling argument that "personal intervention must be balanced with societal intervention" (p. 17) and presents evidence that added sugar, and by extension the category of ultraprocessed foods, meets the criteria deemed necessary and sufficient for public health regulatory policy. He then proposes a number of societal interventions, including public education, taxation, subsidies, and restricted access, that have been found effective in reducing the risk and impact of other public health issues. Wiss, Avena, & Gold [4] present a conceptual biopsychosocial model showing how early adversity, trauma, and stress may become biologically embedded and interact with psychological, social, and environmental factors to increase the risk of addiction, including food addiction. Following this model, they recommend a multilevel approach for reducing the risk and impact of food addiction that includes both individual and public health interventions.

Other authors examined the similarities between food addiction and other forms of addiction, or the presence of addictive-like eating in other clinical populations. Zawertailo et al. [5] conducted a narrative scoping review to examine commonalities between food addiction and tobacco use disorder and identified some shared biopsychosocial vulnerability factors (e.g., childhood adversity, attachment insecurity, dopaminergic neurocircuitry) and underlying mechanisms that may help to inform treatment options. They also included the results of a small pilot study examining food addiction among individuals seeking treatment for tobacco use disorder. The research conducted to date has primarily examined food addiction among individuals with other forms of addictions or eating disorders given their overlap, and Stogios et al. [2] extended this line of research into a new clinical population in their scoping review of eating behaviours among individuals with psychosis.

Collectively, the articles included in this special issue suggest that individuals with food addiction, and particularly those presenting for treatment of food addiction, often have comorbid psychiatric diagnoses, body image concerns, and impaired quality of life, and that many health care professionals who potentially work with such patients feel that they need additional knowledge of, and training in, assessment and evidence-based treatments for food addiction. Similar to other addictions such as tobacco use disorder, a multicomponent approach including both individual and societal intervention is warranted to reduce the personal and public health impact of food addiction.

As research attention shifts from examining the validity to the clinical utility of food and eating addiction, many questions remain to be answered. What factors predict treatment seeking among individuals with food or eating addiction? What are the treatment preferences of individuals with food or eating addiction? Are existing evidence-based treatments for eating disorders or substance-related and addictive disorders effective among individuals with food or eating addiction? What can be done to improve the durability of treatment effects of those interventions that have already been examined and found to improve only short-term outcomes? What is the evidence for abstinence-based versus moderation approaches? How do patients experience each of these interventions? What do they find helpful and unhelpful, and what do they attribute any changes to? Recognizing that "one size will not fit all", how can we move to personalized approaches to food addiction treatment (i.e., what treatment for whom)? We hope that the articles included in this special issue will provide the impetus to explore these important questions and generate knowledge to inform clinical practice guidelines.

**Author Contributions:** Both authors conceptualized and contributed to writing this editorial. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

