Treating Overweight as Carbohydrate Addiction
Jeffrey L. Tate, MD
jtate@tatehealthcare.com
479-271-6511
American Journal of Bariatric Medicine 25(2):2010 pp 13-15
(Posted by permission of the American Society of Bariatric Physicians)
In recent years there has been a growing sense that obesity may be, at least in part, due to addictive behaviors with regard to food.1, 2, 3 Based on this concept, since 1998 I have treated overweight as a substance abuse disorder, with food as the abused substance. I now have experience treating about 2400 overweight patients using this clinical model.
Virtually all the overweight patients in my practice report that the foods they most frequently over-consume are sweets and/or starches—that is, high-carbohydrate foods. No patient has reported that her “problem foods” were protein, non-starchy vegetables, or fats. When, during treatment, consumption of sweets and starchy foods is drastically reduced (with no restriction on fat or calorie intake), weight loss is rapid and can continue down to a healthy BMI (body mass index) of less than 25 kg/m2 in many patients. These two facts have led me to conceive of overweight as a complication of, specifically, excessive carbohydrate consumption.
The pattern of patients’ behaviors regarding sugary and starchy foods strongly suggests a substance abuse problem. For example, many patients come to treatment already aware that sugary and starchy foods are causing their overweight. Many of these patients previously have attempted to limit their consumption of high-carbohydrate foods, and they have found themselves unable to do so.
Individuals who attempt to reduce their carbohydrate intake often have “withdrawal symptoms” of irritability, anxiety, depression, and intense cravings for sugary or starchy foods. Almost always, after several days of carbohydrate restriction cravings for sugary or starchy foods become irresistible. Individuals’ “carb cravings” are intensified by stress, the sight and smell of sugary or starchy foods, or other triggering cues, such as driving by a fast-food restaurant. Many 
patients report that they feel “out of control” in overeating sugary or starchy foods.
Because these typical behavior patterns so closely resemble that of substance abusers and addicts who attempt sobriety, I have evolved toward identifying overweight patients as “carbohydrate addicts.”
Using a carbohydrate addiction model, the aim of treatment becomes lifelong “carb sobriety” rather than just weight loss. Carb sobriety means permanently limiting sugar-starch intake so never to adversely affect health (including avoiding all elements of the metabolic syndrome), and, importantly, so never to re-stimulate irresistible cravings for high-carb foods.
For some patients carb sobriety means learning to eat sugary-starchy foods in well-controlled moderation. For many patients, however, carb sobriety means almost never eating sugary-starchy foods again (“carb abstinence”) because of their great vulnerability to quick resurgence of intense carb cravings (this can be done; I personally have eaten virtually no sugary-starchy foods since late 1998).
The therapeutic tools I use are those typical of substance abuse treatment: patient education in the carb-addiction model, stages-of-change theory4, motivational interviewing5, relapse prevention and recovery counseling6, cognitive therapy7, and solution-focused therapy.8
While the literature describing these treatment techniques usually refers to alcoholism, often little is needed beyond changing the noun “alcohol” to “sugar and starch” in order to apply these techniques to the carb addiction treatment model.
The low-carbohydrate diet I prescribe is similar to the Atkins diet.(9) The effectiveness and safety of low-carbohydrate diets are well supported in the literature.(10, 11) The goal of the diet is to minimize the consumption of “net carbohydrates,” which are calculated by subtracting the fiber and sugar-alcohols (artificial sweeteners) from a food’s total carbohydrate content. Essentially, sugary and starchy foods are nearly eliminated from the diet. There is no restriction of calorie or fat consumption.
I prescribe 30 minutes of strength-training exercise twice weekly. I also prescribe medications that reduce appetite, reduce cravings for high-carb foods, and that minimize the dysphoria that reduction of carbohydrate intake can cause within the first couple of weeks.
Based on an analysis, as of January 2008, of the 43 overweight patients who entered my practice in February 2007:
- 82% of patients are female
- For all 43 patients (including two patients who did not return after the intake interview) average weight loss was 24 lbs (SD 16 lbs), 12% of initial weight, a change of BMI from 35 kg/m2 (SD 6 kg/m2 ) to 31 kg/m2 (SD 5 kg/m2 )
- 47% of patients (19) attended at least six monthly office visits; they lost an average of 41 lbs (STD 14 lbs), 16% of initial weight, a decrease of BMI from 38 kg/m2 (STD 8 kg/m2) to 30 kg/m2 (STD 6 kg/m2)
- 16% of patients (7) attended at least 10 monthly office visits; they lost an average of 51 lbs (SD 8 lbs), 20% of initial weight, a decrease of BMI from 43 kg/m2 (SD 7 kg/m2) to 34 kg/m2 (SD 5 kg/m2 )
As with any substance abuse recovery program, immediate, permanent success is not typical. Patients go through periods of relative carb abstinence during which they lose weight very well. Many patients experience short lapses of increased carbohydrate intake, and some patients have relapses of longer periods of high carbohydrate intake when they again feel out of control of their eating and regain weight rapidly. As they go into lapses, patients exhibit the same type of addictive “stinkin’ thinkin’” rationalizations for “using” sugars and starches as do abusers of any other substances. Becoming consistently carb sober often involves a long learning process. Lapses and relapses back to high-carb consumption should be handled as learning opportunities. The treatment expectation is a prolonged course of recovery, with progressively longer periods of carb sobriety, and progressively less frequent relapses that are both briefer and less severe.
During the maintenance phase of treatment, patients must find out (1) how many net carbs per day will maintain their weight, and (2) how much they can add back their most tempting high-carb foods without stimulating uncontrollable carb cravings. This is a matter of experimentation with close therapeutic support.
Medications
Because I view overweight as a substance abuse disorder, medication treatment for overweight is as justified as it is in treating alcoholism, smoking, or any other addiction.
If the patient’s BMI is 27 or greater, I usually prescribe phentermine 37.5 mg, ½ tablet in the morning and ½ tablet about 3 p.m. I also begin a serotonin reuptake inhibitor (SSRI), usually citalopram 10 mg every morning. I prescribe metformin ER 500 mg at bedtime.
Phentermine, of course, suppresses appetite. It has a reputation for effectiveness of only several weeks’ duration. However, adding an SSRI usually extends phentermine’s effectiveness for several months. Metformin improves insulin sensitivity, thus lowering excessive insulin production. With this medication regimen, combined with a low-carbohydrate diet, overall appetite is reduced for the first one to two months. Then appetite begins to return to normal, but cravings for carbohydrates remain low as long as re-exposure to sugars and starches is minimal. In my practice, metformin usually speeds weight loss by two to six pounds per month, and many patients perceive metformin as the most important medication for reducing their carb cravings.
So far, my patients have experienced no dangerous side effects on this medication regimen. No patient has shown an abusive pattern of phentermine use, or withdrawal symptoms when phentermine was abruptly discontinued. There have been no identified cases of primary pulmonary hypertension or cardiac valvulopathy (chest and cardiac auscultation are performed at each monthly office visit). Uncommonly, increased blood pressure requires that phentermine be discontinued. Most commonly, preexisting hypertension begins to improve within the first month of treatment.
Patient Education about Carb Addiction
Patients are taught that their primary problem is not overweight. Rather, overweight is one of the physical complications of their addiction to sugary and starchy foods. Patients are taught that lifelong “carb sobriety” is the goal.
Patients are taught that carb-addiction recovery will be a lifelong learning task; that they will always be “recovering” carb addicts, even after they have attained their goal weight; that they will live forever with the danger of relapse into high-carb food abuse, against which they will need to be forever vigilant. They are taught that, lifelong, food consumption decisions should not be based on a food’s likely short-term effect on weight; rather food decisions must be made on the likely effect on habits and carb cravings.
When, sometime during the initial visit, I talk to patients about this carb-addiction model as an explanation for their years-long struggle with overweight, many patients experience an “ah-ha” moment. Some are moved to tears. Usually, this model fits their subjective experience of their difficulty controlling eating extremely well. Many have a powerful sense of understanding the nature of their weight problem for the first time.
Countertransference
The addiction model of overweight helps minimize negative countertransference in the treating clinician. Using the addiction model, we expect lapses and relapses. We understand that complex biochemical, psychological, and social forces encourage relapse back to high-carbohydrate consumption. Setbacks are expected and are used as learning opportunities to become better prepared to move higher up the carb-sobriety learning curve. Understanding this typical course of addiction recovery helps prevent excessive frustration and loss of hope in both the patient and the therapist.
Conclusion
I have found the carbohydrate addiction model very useful in treating overweight patients. Patients virtually always feel that their own experience with food fits this model well. Adherence to the low-carb diet produces consistently good weight loss results, with no adverse health effects. Medications and addiction counseling methods provide effective tools for helping the patient achieve carbohydrate sobriety in the long-term.
At this point, more outcome data regarding the carbohydrate addiction model for treatment of overweight is needed.
The traditional medical model of overweight treatment has been notoriously unsuccessful. A new approach is needed. An addiction model of overweight offers a new paradigm for generating treatment techniques.
For further information about my experience in treating overweight patients, e-mail me at jtate@tatehealthcare.com.
References:
[1] Riva G, Bacchetta M, et.al., Is severe obesity a form of addiction?: Rational, Clinical Approach, and Controlled Trial. CyberPsychology & Behavior. 2006:9:457-479
[2] Collins, RE. Relapse Prevention for Eating Disorders and Obesity. In Marlatt, G. and Donovan, D. eds. Relapse Prevention, 2nd Edition. New York: Guilford Press; 2005.
[3] Volkow, N.., Wise, RA. How can drug addiction help us understand obesity? Nature Neuroscience. 2005:5 555-560
[4] Connors, J., Donovan, D., DiClemente, C. Substance Abuse Treatment and the Stages of Change. New York: Guilford Press; 2001
[5] Miller W., Rollnick, S. Motivational Interviewing. New York: Guilford; 2002.
[6] Marlatt, G. Donovan, D. Relapse Prevention 2nd Edition. New York, Guilford Press; 2005.
[7] Beck, A., Wright, F., Newman, C., Liese, B. Cognitive Therapy of Substance Abuse. New York: Guilford; 1993.
[8] Guterman, J. Mastering the Art of Solution Focused Therapy. Alexandria, VA: American Counseling Association; 2006.
[9] Atkins, R. Dr. Atkins’ New Diet Revolution. New York: HaperCollings; 2002.
[10] Meckling KA, O’Sullivan C, Saari D. Comparison of a low-fat diet to a low-carbohydrate diet on weight loss, body composition, and risk factors for diabetes and cardiovascular disease in free-living, overweight men and women. J Clin Endocrinol Metab. 2004; 89(6):2717-23.
[11] Yancy WS, Oslen MK, Guyton, JR, et. al. A low-carbohydrate ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: A randomized, controlled trial. Ann Intern Med. 2004; 140(10):769-77.
[12] Beck, A., Wright, F., Newman, C., Liese, B. Cognitive Therapy of Substance Abuse. New York: Guilford; 1993.