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How much does the Addiction-Like Eating Behavior Scale add to the debate regarding food versus eating addictions?

Recently in the International Journal of Obesity, Ruddock et al.1 validated the Addiction-Like Eating Behavior Scale (AEBS), which measures eating as a behavioral addiction. This contrasts the Yale Food Addiction Scale (YFAS), which adapts the Diagnostic and Statistical Manual substance-use disorder (SUD) criteria2 to operationalize a food addiction to high-fat/sugar foods.3, 4 These differing perspectives reflect a debate in the field regarding whether addictive-like eating is more appropriately conceptualized as a behavioral eating addiction or a substance-based food addiction.5, 6 We agree with Ruddock et al.1 that an addiction framework may have important implications for eating-related problems and obesity. However, we believe that the AEBS does not parallel theoretical perspectives of behavioral addictions and cannot differentiate between eating versus food addiction.

Ruddock et al.1 state that the AEBS overcomes limitations of the YFAS by assessing behavioral features of an eating addiction. Yet, all addictive disorders, including both SUDs and gambling disorder, are diagnosed based on behavioral criteria (for example, continued use/engagement despite negative consequences). Indeed, the YFAS also relies on behavioral indicators to operationalize food addiction. Rather, the distinguishing feature between SUDs and behavioral addictions is whether there is a substance that may perpetuate compulsive use. Thus, validity of an eating (versus food) addiction relies on evidence that (specific) foods do not contribute to the addiction phenotype.

However, the AEBS specifically assesses eating-related problems associated with ‘unhealthy’, ‘processed’ and ‘high-fat/sugar foods’. This reflects animal and human studies demonstrating these foods are ones most implicated in addictive eating7, 8 and aligns with a food addiction framework. Assessment of problematic eating behavior to all foods equally would be more consistent with a behavioral addiction perspective.

Additionally, moving away from Diagnostic and Statistical Manual criteria potentially raises concerns about whether the AEBS is a comprehensive measure of addiction. Many items may assess overeating more generally (for example, ‘I serve myself overly large portions’). While heavy use of substances or frequent engagement in gambling is one component of addiction,2 it is not sufficient to characterize whether an individual is experiencing a clinically significant addictive disorder (for example, frequent gambling is not synonymous with gambling disorder).

In summary, we agree with Ruddock et al.1 that applying an addiction framework to food consumption likely has significant clinical implications. However, we believe that the AEBS may not measure eating as a behavioral addiction due to possible misconceptions about the role of behaviors in assessing all addictive disorders, the specific assessment of eating-related problems with high-fat/sugar foods and limited inclusion of addiction criteria. Broadly, we suggest that the perspective of eating as a behavioral addiction does not follow from existing data on this topic. Thus, this debate may distract from investigating key questions for establishing the validity of food addiction, such as which food ingredients (for example, sugar) may be addictive, the overlap between food addiction and binge-eating disorder and the clinical utility of applying an addiction framework to some forms of problematic eating behaviors.

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Correspondence to E M Schulte.

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The authors declare no conflict of interest. Dr Potenza has: consulted for and advised Rivermend Health, Opiant/Lakelight Therapeutics and Jazz Pharmaceuticals; received research support (to Yale) from the Mohegan Sun Casino and the National Center for Responsible Gaming; and consulted for legal and gambling entities on issues related to impulse-control disorders and addictions.

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Schulte, E., Potenza, M. & Gearhardt, A. How much does the Addiction-Like Eating Behavior Scale add to the debate regarding food versus eating addictions?. Int J Obes 42, 946 (2018). https://doi.org/10.1038/ijo.2017.265

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