**Aymery Constant 1,2,**†**, Romain Moirand 1,3,**†**, Ronan Thibault 1,4,**† **and David Val-Laillet 1,\*,**†


Received: 9 October 2020; Accepted: 18 November 2020; Published: 20 November 2020

**Abstract:** This review, focused on food addiction (FA), considers opinions from specialists with different expertise in addiction medicine, nutrition, health psychology, and behavioral neurosciences. The concept of FA is a recurring issue in the clinical description of abnormal eating. Even though some tools have been developed to diagnose FA, such as the Yale Food Addiction Scale (YFAS) questionnaire, the FA concept is not recognized as an eating disorder (ED) so far and is even not mentioned in the Diagnostic and Statistical Manuel of Mental Disorders version 5 (DSM-5) or the International Classification of Disease (ICD-11). Its triggering mechanisms and relationships with other substance use disorders (SUD) need to be further explored. Food addiction (FA) is frequent in the overweight or obese population, but it remains unclear whether it could articulate with obesity-related comorbidities. As there is currently no validated therapy against FA in obese patients, FA is often underdiagnosed and untreated, so that FA may partly explain failure of obesity treatment, addiction transfer, and weight regain after obesity surgery. Future studies should assess whether a dedicated management of FA is associated with better outcomes, especially after obesity surgery. For prevention and treatment purposes, it is necessary to promote a comprehensive psychological approach to FA. Understanding the developmental process of FA and identifying precociously some high-risk profiles can be achieved via the exploration of the environmental, emotional, and cognitive components of eating, as well as their relationships with emotion management, some personality traits, and internalized weight stigma. Under the light of behavioral neurosciences and neuroimaging, FA reveals a specific brain phenotype that is characterized by anomalies in the reward and inhibitory control processes. These anomalies are likely to disrupt the emotional, cognitive, and attentional spheres, but further research is needed to disentangle their complex relationship and overlap with obesity and other forms of SUD. Prevention, diagnosis, and treatment must rely on a multidisciplinary coherence to adapt existing strategies to FA management and to provide social and emotional support to these patients suffering from highly stigmatized medical conditions, namely overweight and addiction. Multi-level interventions could combine motivational interviews, cognitive behavioral therapies, and self-help groups, while benefiting from modern exploratory and interventional tools to target specific neurocognitive processes.

**Keywords:** obesity; craving; reward circuit; motivation; cognition; behavior; therapy

### **1. Introduction**

Even though the concept of food addiction (FA) was introduced more than sixty years ago [1], its definition and implications are still fiercely debated [2,3]. Highly palatable foods [4,5], such as processed foods with added sugars and fat, could be as addictive as drugs [6,7], acting via the same neurocognitive and hedonic processes [8,9]. Therefore, through the alteration of the neurocognitive systems involved in food intake control [10], FA could be involved in the obesity pathogenesis. However, at this time, the concept of FA is still debated [2,3,11] and is probably entangled with complex psychological factors and predispositions. The concept of sugar addiction is well defended in animal models [12], but in humans, some authors rather suggest the concept of "eating addiction", i.e., an addiction to the eating behavior instead of an addiction to palatable foods like sugar or saturated fat. Nevertheless, considering the alterations of the neurocognitive systems involved in food intake control [10], the diagnostic criteria of FA were based on the Diagnostic and Statistical Manuel of Mental Disorders version 5 (DSM-V) criteria for substance use disorders [13]. In clinical practice, the Yale Food Addiction Scale (YFAS) 2.0 is the only self-administered questionnaire validated to diagnose and estimate the number of symptoms of FA [14,15].

Our first aim is to better describe the place of FA in the current nosography and establish a parallel between FA and other ED or addictive disorders, while discussing possible transfer or continuity between disorders. Our second aim is to illustrate, on the basis of existing data, how FA is frequent in the general and obesity population and how it articulates with comorbidities in obese patients. We also discuss why and how FA should be handled in the preoperative management of obesity surgery patients. Our third aim is to highlight the relationship between FA and specific psychological features, within a continuum ranging from normal to disordered eating. Our fourth aim is to describe the neurocognitive and brain correlates with other substance use disorders (SUD), such as with drugs and alcohol, to support a neurobiological picture of FA. Finally, we discuss the concept of FA in the context of prevention, diagnostic, and treatment, with the aim to present existing or innovative strategies in the scope of interdisciplinary and personalized medicine. Perspectives in terms of cognitive and behavioral therapies, digital technologies, and neuromodulation interventions are also discussed.
