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Ashley N. Gearhardt, Kelly D. Brownell, Mark S. Gold, and Marc N. Potenza, editors.  Food & Addiction: A Comprehensive Handbook, Second Edition.  Oxford University Press, 2024.  570 pages.

This is the second edition of a book I wrote about in 2012.

At the time, I said:

Brownell and Gold have produced an instant classic.  Food and Addiction presents a comprehensive, authoritative, and compelling case for considering whether food is addictive.  Its chapters raise serious questions about our current laissez-faire attitude toward food marketing, especially to children.  This book is a must read for everyone who cares about the causes and consequences of obesity and the need for food policies that better promote health.  It is a game changer.  Readers will never look at food the same way again.

Much has happened since then to focus greater attention on the ways food triggers addictive-like eating behavior.

• Michael Moss’s books, Salt, Sugar, Fat, and Hooked.  These document how food companies deliberately formulate products to make them irresistible (“you can’t eat just one”).
• The emergence of the concept of ultra-processed foods as a researchable category.
• Kevin Hall et al’s demonstration that ultra-processed foods encourage people to eat more calories but not realize it.
• The increase in research using the Yale Food Addiction Scale, and
• The research described and reviewed in this book.

All of this makes an increasingly convincing case that the word “addiction” applies to food as well as to other addictive substances, and that similar proportions of people (10% to 15%) meet criteria for addiction; everyone eats, but not everyone meets those criteria.

The editors’ introductory and concluding chapters lay out the diagnostic and policy issues.

The short chapters address biological, behavioral, clinical, and legal correlates of food addiction.

They are written by a authors who address these issues from enormously different , but highly critical, perspectives ranging from the exceedingly personal to the big-picture political.

Is anything missing here?  As with any multi-authored book, this one undoubtedly took years to produce.  That makes it a few years out of date in fast-moving areas.  It does not cover recent research on ultra-processed foods, Kevin Hall’s experiment, the concept of food “noise,” or the way the new GLP-1 drugs might interact with addictive behavior.

But, this is the resource of food addiction, a great gift to the addiction-perplexed and an enormous public service at a time when it is badly needed.

What started all this was this graph of obesity prevalence in the US from the Financial Times:

The most complete account of what happened next comes from Helena Bottemiller Evich in Food Fix (a must-read for anyone interested in following the food scene): “Have we passed peak obesity? New data sparks speculation.”

The Financial Times was the first to pick up on new data from the Centers for Disease Control and Prevention showing that the obesity rate for U.S. adults declined two percentage points between 2020 and 2023. The headline from across the pond was upbeat: “We may have passed peak obesity.” Soon, a couple of other news outlets followed, including Axios: “Americans are getting healthier by some key metrics.” The Washington Post editorial board jumped into the fray this week as well: “The obesity rate might have stopped growing. Here’s what could be working.”

The original data came from the CDC:

Plotted this way, the decline is not nearly so impressive (and severe obesity is increasing slightly).

As for the effect of the drugs, it’s much too early to say, says the epidemiologist Deirdre Tobias posting on Twitter (X).

The downtick occurred before the drugs were widely used.  Following her thread produces lots more data on that point.

We will have to wait a few more years to know how all this will play out.  I can’t wait!

As I keep saying, eating less is bad for business.

If you need proof, just look at how the food industry is scrambling to figure out what to do in response to the effects of GLP-1 drugs in decreasing appetite and food “noise.”

Here are a few examples.

The threat

Weight loss drugs may be melting US ice cream demand: Demand for frozen dairy products in the US has been declining for decades. Consumers’ growing interest in GLP-1 weight loss products is putting further pressure on demand…. Read more

Ozempic’s Effect on Food Innovation: Anti-obesity drugs have dropped on the food business in the last year like ChatGPT has dropped on the world. And according to experts assembled for a recent Mattson webinar on the topic, the effects of new appetite suppressants including Ozempic, Wegovy, and Zepbound have only begun to be felt among American consumers and the food industry that sells to them.

The promise

Nestlé introduces Vital Pursuit brand to support GLP-1 users in the US: Nestlé is introducing Vital Pursuit, a new line of foods intended to be a companion for GLP-1 weight loss medication users and consumers focused on weight management in the US. The products are high in protein, a good source of fiber, contain essential nutrients, and they are portion-aligned to a weight loss medication user’s appetite. The new line is also well-suited to support a balanced diet for anyone on a weight management journey. Vital Pursuit is the first food brand from Nestlé intended for GLP-1 users with the goal of complementing the eating habits of millions of Americans who are currently prescribed a weight loss medication or actively working to manage their weight.

Food Companies Want a Piece of the Ozempic Pie, Too: Last fall, word of a looming existential threat to the packaged food industry began to bubble up in earnings calls and among analysts. Drugs such as Ozempic, Wegovy and Mounjaro, experts feared, could be a little too effective at curtailing people’s cravings for snacks and sweets, and if too many people got on the drugs, their changing habits could eventually do the industry real harm. Could buyers begin to forsake Doritos and Oreos and Pizza Bagels?

Danone Targets Health, Nutrition as Food Industry Braces for Ozempic Era: The food company is targeting like-for-like sales growth of 3%-5% for the 2025 to 2028 period, with operating income rising at a faster pace than sales. Danone plans to double down on health and nutrition in the coming years as food companies seek to tackle the effects of Ozempic and other blockbuster weight-loss drugs on eating habits.

Supergut’s Marc Washington on ‘Ozempic era’ opportunity: The IPA World Congress + Probiota Americas 2024 in Salt Lake City highlighted many of the innovations happening in the prebiotics space, including how GLP-1s are impacting the category…. Watch now

I was thrilled to be invited to be on Oprah last week to discuss the influence of the food environment on obesity.  Alas, I was disinvited when the topic switched to fat shaming.

While recovering from the disappointment, I ran across this article in FoodDive: The Ozempic effect is real: Study zeroes in on GLP-1 users’ food needs.

A study found people taking anti-obesity medications such as Ozempic, Wegovy and Zepbound to be looking for:

• Foods packed with protein
• Smaller portions
• Foods that help quell nausea
• Foods that help reduce gastrointestinal side effects

The potential size of this market is impressive:

Manufacturers looking to create products that cater to this growing market segment – which according to recent research from Goldman Sachs could be as much as 15 million people, or 13% of the U.S. population, by 2030 – should focus on creating products that meet their new needs.

The research group used “its proprietary AI to generate food concepts that it had panel participants evaluate and several were appealing including:

• Pre-portioned grilled chicken strips
• 2-ounce portions of Greek yogurt in pouches
• Electrolyte-enhanced fruit popsicles
• Mini meal cups

Hey—this is a win-win.  First the food industry makes products that people can’t resist eating and make them gain weight.  Then the industry creates products that help them take drugs more easily.

A marketing opportunity for all

Today I’m participating on a panel discussion on Ozempic at 12:30 EDT.  See announcement to the right; register for it here. 

I watched the Oprah special on the obesity drugs.

Its messages:

• Obesity is a disease, requiring treatment.
• These drugs offer treatment.
• The drugs are effective; side effects are minimal.
• Yes they are expensive and therefore, promote inequality; therefore, the government should pay for them.

The program was a one-hour, prime-time commercial for the drugs.

The physicians who testified on their behalf consult for the drug companies.

The program has already had an effect.  cause the FDA says semaglutide helps prevent heart attacks, strokes, and deaths in overweigth people, the government will now authorize payment through Medicare Part D.

Here’s what was not discussed.

• The fortunes the drug companies spent on getting doctors, health professionals, and influencers to promote the drugs and minimize their side effects.  See Reuters for US doctors and The Guardian for European influencers.
• The sharp rise in obesity prevalence between 1980 and 2000 and the environmental and commercial reasons for it.
• Anything about prevention. and changing that food environment.
• Anything serious about the down side of taking the drugs (lifetime treatment, cost, side effects, loss of joy in eating).

An editorial in The Lancet says:

A simple pill or injection will undoubtedly help some patients, but it cannot be the sole basis for addressing the complexities of obesity. Obesity is a product of not only an individual’s circumstances and behaviour, but also society at large, shaped by global food markets and trade agreements. Multidimensional approaches are needed to curb the effects of the obesogenic environment, particularly against an international industry that promotes overproduction of cheap food and drinks. Physical activity needs to increase; walking and cycling for journeys to work or school should be normalised and made easier and safer. Sugar taxes and curbs on marketing of high-energy, high-fat, ultra-processed foods need to be implemented. Prevention must be the foundation upon which everything else follows.

Other comments

• The New York Times account focuses on stigma.
• USA Today says people are suing the drug companies over side effects.

Much to be said about all this.  Stay tuned.

DRUGS

Here’s the headline: Maker of Wegovy, Ozempic showers money on U.S. obesity doctors

Drugmaker Novo Nordisk paid U.S. medical professionals at least $25.8 million over a decade in fees and expenses related to its weight-loss drugs, a Reuters analysis found. It concentrated that money on an elite group of obesity specialists who advocate giving its powerful and expensive drugs to tens of millions of Americans.

What’s extraordinary about this situation is the amounts.  Some doctors got millions.

This account follows one about similar efforts in the UK: Revealed: experts who praised new ‘skinny jab’ received payments from drug maker.

The drug giant behind weight loss injections newly approved for NHS use spent millions in just three years on an “orchestrated PR campaign” to boost its UK influence.  As part of its strategy, Novo Nordisk paid £21.7m to health organisations and professionals who in some cases went on to praise the treatment without always making clear their links to the firm, an Observer investigation has found.

Novo Nordisk knew what it was doing, and its efforts (presumably legal) are certainly paying off.

ALCOHOL

The headline: Scientists in Discredited Alcohol Study Will Not Advise U.S. on Drinking Guidelines: Two researchers with ties to beer and liquor companies had been named to a panel that will review the health evidence on alcohol consumption. But after a New York Times story was published, the panel’s organizers decided to drop them.

Five years ago, the National Institutes of Health abruptly pulled the plug on an ambitious study about the health effects of moderate drinking. The reason: The trial’s principal scientist and officials from the federal agency’s own alcohol division had solicited $60 million for the research from alcohol manufacturers, a conflict of interest and a violation of federal policy.

I wrote about that in a previous post.

I’m told by people in the know that I should not be too hard on the scientists.  NIH told them it would not fund the study and they should get the funding from industry.  If true, that is unfortunate.

For sure, NIH is not interested in nutrition research except for genetically based “Precision” nutrition aimed at individuals.  That leaves population studies out of the picture.  Unfortunate, indeed.

CLINICAL TRIALS

The study: Industry Involvement and Transparency in the Most Cited Clinical Trials, 2019-2022

Among 600 clinical trials with a median sample size of 415  participants:

• 409 (68.2%) had industry funding
• 303 (50.5%) were exclusively industry-funded
• 354 (59.0%) had industry authors
• 280 (46.6%) involved industry analysts
• 125 (20.8%) were analyzed exclusively by industry analysts.

Among industry-funded trials:

• 364 (89.0%) reached conclusions favoring the sponsor.

Industry involvement in research in general and in nutrition research in particular deserves close scrutiny and much skepticism.

Drug companies are required to do research and to find their own funding.  That is not true of nutrition.

Everyone should be lobbying for more independent funding for nutrition research.

Lots of people take supplements in the hope that they will help with body weight.  This is a big market.  Drug companies want in on it.  Most drugs don’t work, or have deal-breaking side effects.  In June,  The FDA approved Novo Nordisk’s Semaglutide for obesity management.

I subscribe to the Obesity and Energetics newsletter, which sends out weekly lists of research, articles, and commentary on those topics—a great way to stay up on current literature.

On July 2, it featured:

• From the Obesity Society: “Health care providers should be aware of the lack of evidence and deficiencies in regulatory oversight of dietary supplements marketed for weight loss.”  

This referred to: Perspective: Dietary supplements and alternative therapies for obesity: A Perspective from The Obesity Society’s Clinical Committee.  Srividya Kidambi, John A. Batsis, William T. Donahoo, Ania M. Jastreboff, Scott Kahan, Katherine H. Saunders, Steven B. Heymsfield.  Obesity 23 June 2021.

Our recommendation to clinicians is to consider the lack of evidence for non-FDA-approved dietary supplements and therapies and guide their patients toward tested weight management approaches…we call on regulatory authorities to critically examine the dietary supplement industry, including their role in promoting misleading claims and marketing products that have the potential to harm patients.

I am with the Obesity Society on this one, but what caught my interest was that several of the authors report financial tied to drug companies with interests in pharmacologic approaches to obesity treatment.

Conflicts of interest: SK serves as Medical Editor for TOPS Magazine (TOPS Inc. nonprofit weight loss club) and as Director for the TOPS Center for Metabolic Research at the Medical College of Wisconsin supported by TOPS Inc. JAB’s research reported in this publication was supported in part by the National Institute on Aging of the National Institutes of Health (NIH) under Award Number K23AG051681. JAB reports equity in SynchroHealth LLC. AMJ’s research is supported by the NIH/NIDDK, the American Diabetes Association, Novo Nordisk, and Eli Lilly; she serves as a consultant for Novo Nordisk, Eli Lilly, and Boehringer Ingelheim. SKa has served as a consultant for Novo Nordisk, Vivus, Gelesis, and Pfizer. KHS reports an ownership interest in Intellihealth. SBH reports his position on the Medical Advisory Board of Medifast Corp.

The newsletter also featured the article referred to in the Perspective.

• Systematic Review: Dietary Supplements and Alternative Therapies for Weight Loss.

When I clicked on this link, it took me to the page where I could download the pdf.  I got the paper at this site.   But before I could read it, I had to see an ad for Novo Nordisk’s drug, Semaglutide.  Then I scrolled down to get the study:  A Systematic Review of Dietary Supplements and Alternative Therapies for Weight Loss.  John A. Batsis, John W. Apolzan, Pamela J. Bagley, Heather B. Blunt, Vidita Divan, Sonia Gill, Angela Golden, Shalini Gundumraj, Steven B. Heymsfield, Scott Kahan, Katherine Kopatsis … Obesity (2021) 29, 1102-1113

Study conclusion: “There is weak evidence for the efficacy of dietary supplements and alternative therapies.”

Authors’ disclosure: JAB reports equity in SynchroHealth LLC. AG reports consulting with Novo Nordisk and Unjury. SH reports personal fees from Medifast. SKa reports personal fees from Novo Nordisk, Pfizer, Vivus, and Gelesis. DR reports consulting and speaking fees for Novo Nordisk and Astra Zeneca. KHS has a relationship with Intellihealth Inc. SK is the medical director for TOPS Center for Metabolic Health at the Medical College of Wisconsin, which is supported by TOPS Inc. SBH reports his position on the Medical Advisory Board of Medifast Corp.

I much prefer dietary approaches to weight management and policy strategies to make healthy diets the easy choice.

I am almost never in favor of supplements.  The evidence that they do much beyond placebo effects is usually pretty weak.

The ad gives the side effects for Semiglutide; it has to.

My point: all of this seems to be about marketing Semiglutide.

I was riveted by an article in today’s New York Times about the latest decision of an FDA drug advisory panel.

The panel voted to approve a new weight-loss drug, lorcaserin.  The vote was mixed: 18 for approval, 4 against, and 1 abstention. The majority felt that the benefits outweighed the risks and that even if there were risks, “new tools are needed to treat a major health problem.”

The benefits are worth a look.

• People taking the drug lost an average of  5.8% of their body weight in a year, compared to 2.5% for people taking a placebo.  This difference is below the FDA’s standard for approval which requires a 5% difference.
• Among those taking the drug, 47% lost at least 5 percent of their weight after a year, whereas only 23% of those taking the placebo did so.  This meets a second FDA standard for approval.

What about the risks?  The drug:

• Causes tumors in rats (although perhaps at higher doses than might be taken by people).
• Damages heart valves (in the same way the withdrawn drug, Fen-Phen, did).

Also in the Times is a piece by Dr. Danielle Ofri on her experience with patients who want weight-loss drugs.

She quotes from an essay called “Lemons for Obesity” by Dr. Michael S. Lauer, who was a minority voter on the FDA panel that approved the weight-loss drug Qnexa earlier this year.

The weight-loss field is strewn with lemons, more so than other areas of medicine, Dr. Lauer argues. Because of the enormous potential market for these drugs — two-thirds of American adults are overweight or obese — pharmaceutical companies rush new drugs to market after conducting only small clinical trials. The F.D.A. and doctors are complicit in the process, Dr. Lauer says, leaving the population at large to act essentially as guinea pigs.

Shares of the maker of the drug nearly doubled after the decision.  The Times reported that “Arguments by investors have been passionate.”

People who cannot easily lose weight are desperate for help.

But is it ethical to put them at this kind of risk?