Sugar, fat, food and addiction: New approaches to the public health crisis

A FABResearch conference – July 2014

Notes on the presentations by Michelle Berriedale-Johnson

Food and Addiction – an overview – Dr Alex Richardson

Appetite, Satiety and the Obesity Crisis: Why can't people just say 'no' to over eating? – Professor Jason Halford

Sugar, Hormones and Addiction – Professor Robert Lustig

Nutrition and Substance Abuse: Getting the fats right – Captain Joseph Hibbeln

The Role of Food and Diet in 'Addictive' Disorders – Dr Alex Richardson

Addicted to Antisocial Behaviour – Dr Bernard Gesch

Psychosis and addiction: Nutritional Interventions in Mental Health – Kevin Williamson

How a public health policy addressing the crisis could be implemented.
Professor Graham MacGregor is aiming to persuade industry to reduce the quantity of sugar in manufactured food, as he did with salt.
Professor Simon Capewell make the case for government intervention.


Food and Addiction – an overview

Dr Alex Richardson, Senior Research Fellow at the Centre for Evidence Based Intervention, University of Oxford. Founder Director FABResearch

Abundant evidence now links modern, western-style diets, rich in highly processed, refined foods, not only to physical health problems such as obesity, type II diabetes, cardiovascular disease and cancer but to mental health disorders such as ADHD, anxiety, depression and psychosis. But public health messages remained confused and anti-fat, often preferring sugar to a high fat diet; there is little understanding that what damages the body also damages the brain.

Yet the scale of the mental health crisis facing the world is now massive. Mental health care, which cost £77 billion in 2007 had risen to £105 billion by 2010 while across Europe the figures are even more mind boggling. 38% of Europeans now have a diagnosable mental disorder, from anxiety to dementia.

In 2010 €798 billion was spent on addiction across Europe and if you include the figures for alcohol and nicotine addiction that rises to €350 billion, substance use disorders accounting for much of that bill. But what is addiction? And what are seen as addictive substances? Not just alcohol, drugs and cigarettes but how about coffee, healthy energy drinks, prescription medicines, food?

When discussing addiction nutrition is still largely ignored. Yet there are 39 essential nutrients that we all need to function, including fats, yet many are lacking in most diets and very few people get them all. But nutrient deficiencies stunt neural networks. A child whose mother was nutritionally inadequate may have 50% fewer neural synapses than a child whose mother was properly nourished. And malnutrition in early life can affect both physical and mental outcomes throughout life.

Modern 'high fat' diets are almost always high in Omega 6 fatty acids and also high in sugar.
The ratio of Omega 3 to Omega 6 should be 1 to 1 but in modern Western diets it is 1 to 15. Yet Omega 6 fatty acids are pro-inflammatory and pro-thrombotic (make clots) while Omega 3s are anti-inflammatory and anti-thrombotic so, if there is to be an imbalance, it should be the other way around.

The brain is 60% fat – but fat is not a single substance – it is the type of fat that matters.


Appetite, Satiety and the Obesity Crisis: Why can't people just say 'no' to over eating?

Professor Jason Halford, Reader in Appetite and Obesity, Psychological Sciences, University of Liverpool

Why do people overeat? Is it biological? Environmental? Or the expression of appetite?

Hunger is a response to a physiological need but we rarely experience genuine hunger; what we perceive as hunger pangs are habituation cues.

Wanting. We want a food because we like it, both consciously and unconsciously.

Satiation and satiety. Eating is brought to an end because we are full and hunger is suppressed so we have no further need to eat.


Many energy dense foods are very palatable, so we are tempted to eat more regardless of whether we are hungry or full. Palatable foods also delay the physical feeling of fullness. High carbohydrate foods are more satiating than most high fat foods although that does depend on the fat concerned.

Overeating means consuming an excessive volume of energy dense foods.
(Adding volume by consuming non-caloric liquids with a meal reduces overall amount of calories consumed but consuming alcohol with a meal only stimulates higher intake.)

Sugar does reduce post meal appetite but its effects are very transient so the person is hungry again very soon after the meal. This effect is particularly noticeable with fizzy drinks where any satiety effect is extremely short lived.

Obese people:
• Do not have normal appetite responses but respond almost entirely to palatability. So, although they do not fit current diagnostic criteria for addiction, they feel 'addicted' to the foods that they over consume.
• Overconsumption disregulates the biological pattern of eating so becomes uncontrollable.
• Obese people are heavily influenced by environment and advertising.

Advertising, especially to children, is extremely potent.

The new regulations have had little real effect as, instead of promoting the foods, advertisers just promote their brands. Research suggests that:
• Although obese children remember more food ads, all children, fat and thin, eat more after seeing the ads.
• Children are not media savvy – the more they see, the more they eat.
• Celebrities and 'characters' strongly influence eating patterns. For example – the Lineker effect. Children ate more Walker's Crisps whenever they saw him, even when he was on Match of the Day and not promoting crisps at all.
• 'Advergames'. Totally unregulated. They immerse the child in the brand to the point that the child becomes the advocate for the brand.
• One of the most successful brands at using 'advergames' are Chipotle burritos in the US but the average Chipotle burrito packs over 1,000 calories.


Sugar, Hormones and Addiction.

Professor Robert Lustig, Division of Pediatric Endocrinology, University of California, San Francisco

Addiction makes a nonsense of personal responsibility. The balance in the addicted brain is off centre so that it cannot activate rational/responsible responses.

The lay public believe that food, and especially sugar, is addictive.
There are many similarities between food and drugs in terms of the areas of the brain that they effect while binge eating equates very closely with substance abuse. The only difference is that while we do not need drugs to survive, we do need food.


• When you get a pleasurable feeling dopamine is released producing a feeling of reward – but this is short lived (around one hour). It should be controlled by the frontal cortex which indicates satiety – you have had enough.
• However, with an addictive substance (such as morphine or nicotine) the dopamine response is up rated (you need more to trigger an effect) and the control mechanisms (in the front cortex) are inhibited (do not work efficiently).
• A 'normal' person has a lot of dopamine 'receptors' so a little dopamine has a relatively great effect. However, with increased, or excessive, exposure, the receptors get down regulated (become less sensitive) so you need more dopamine to get the same effect.
• Obesity inhibits the efficient functioning of the dopamine receptors so you need more food to trigger the reward the response, so the obese person's weight increases further.
• There is also a genetic element to this as 25% of people have a polymorphism which reduces their number of dopamine receptors e.g. they need to eat or take more to achieve 'reward'.

Leptins and insulin

• The hormone insulin originates in the pancreas.
• It controls the storage of fat in the fat cells. It is also involved in the 'satiety signal' – telling the brain that it has taken in enough energy/food so it should stop telling the body to eat more.

• The hormone leptin originates in the fat cells.
• Leptin tells the brain whether or not the body has enough energy for normal function. If leptin levels are low, the brain thinks that the body is short of energy so it needs to eat more (to get energy) and to do less (to preserve what energy it has).

Leptin 'takes its lead' from insulin so if one does not work, nor does the other. Every obese person has a problem in one or other of these areas.

For example:
If you give a normal 5-year-old a cookie, high in carbohydrate, fat and sugar which drive up leptin levels, the child will bounce off the walls as its leptin is signalling that it has excess energy which needs to be used up (by bouncing off the walls).

If you give an obese child a cookie, nothing happens because that child's leptin receptors and pathway are not working. Its brain does not 'see' the rise in leptin levels so it continues to tell the child to eat more so as to create more energy.

Similarly, if the insulin signal is disrupted the dopamine 'reward pathway' is also disrupted. So the child who is 'insulin resistant' (whose brain cannot 'see' the insulin) thinks that it is starving so it will continue to eat to try to get a 'reward' response.

Insulin suppression?

• The more insulin that is released into the system, the more the obese person will eat and the more weight will be gained.
• But when insulin levels drop, so does carbohydrate consumption in relation to other foods.
• Obese people are carboholics, driven by excess insulin which drives further carbohydrate consumption (and depression).
• Reducing their production of insulin not only reduces their carbohydrate intake but increases the responsiveness of their leptin receptors thus restoring some of the normal pathways.

Fast foods and addiction

Fast foods are made up of salt, sugar, fat and caffeine.

• Salt. Salt is habituating but it is relatively easy to retrain the palate so it is not addictive.
• Fat. Fat is not appealing on its own, only when combined with other ingredients. It is not addictive.
• Caffeine. Definitely addictive.
• Sugar.

Sugar releases opioids and dopamines in the brain – in the same way as alcohol, which is sugar based. Consumption patters are similar: bingeing – withdrawal – craving – bingeing.

But addiction to any substance up-regulates the dopamine pathways and that dopamine up-regulation will persist and will transfer to another substance especially if it follows similar pathways – such as sugar and morphine.

In rats, for example, sucrose causes anxiety. If the rats are deprived of sucrose for three weeks, they are still addicted when they are given access to the sugar once more, and that addiction has spread to other substances.

The jury is still out on whether humans can be 'addicted' to sugar but sugar is definitely 'abused'.

What to do about it?

• Fruit and vegetables – consumption remained stable
• Grains – consumption remained stable
• Meat and dairy products – consumption dropped
• Processed foods – consumption up from 11 to 22% – including 80% of added sugar.

Sugar consumption needs to be reduced to 5% of total.


Nutrition and substance abuse: Getting the fats right

Captain Joseph Hibbeln, Acting Chief, Section on Nutritional Neurosciences, NAAAA, NIH

Chronic alcohol abuse can alter brain function thus creating dependence.

(For general information Captain Hibbeln characterised 5% of the population as 'dependent drinkers', 20% at risk of dependency, 35% as responsible drinkers and 40% as abstainers.)

Alcohol consumption releases dopamine so it feels good – 'reward'. The prefrontal cortex should be able to exert control but cues from memory can induce cravings. If these are satisfied more dopamine is released thus creating a habit. Withdrawal activates stress and the stress hormone, cortisol, so you drink more in order to produce more dopamine so as to feel better. But overuse desensitises the dopamine receptors, so you need more alcohol to achieve a lesser result in terms of satisfaction. Instead of happy you become depressed, miserable, irritable.

Change from Omega 3 to Omega 6 fatty acids

Fat consumption affects the membranes which are the base for signalling. Enzymes will digest whatever they are offered so if the diet is high in Omega 6 fatty acids rather than Omega 3s, that is what the enzymes will digest.

But, excess Omega 6 can:
• Lead to a 15% reduction in dopamine levels
• Cause loss of synaptic connections
• Activate inflammation in the brain leading to anxiety, depression and stress
• Disrupt the satiety mechanism

Alcohol, and possibly smoking, also depletes DHA (docosahexaenoic acid from Omega 3) from the brain. If that is all that is available, the DHA will be replaced with Omega 6 fatty acids.

In an ideal diet (the original Mediterranean diet) there would be an equal intake of Omega 3 and Omega 6 fatty acids. In the early part of the 20th century, calorific intake from Omega 6 fatty acids was negligible; now 8–10% of calories comes from Omega 6 fatty acids.

Can dietary intake of Omega 3 fatty acids redress this situation?

Captain Hibbeln quoted one case of an aggressive alcoholic (who was drinking up to 2 litres of spirits and beers per day) whose drinking pattern was dramatically altered over the course of 21 days by elevating his levels of Omega 3s.

He also quoted work that his group had done on the ALSPAC study (an ongoing study following a large group of mothers and children in the Bristol are from their birth in the early 1990s). This showed that the children of meat eating mothers had a lower risk of alcohol, cannabis and smoking problems in their early to mid 20s, while the children of vegetarian mothers with a high consumption of pulses and soya proteins (Omega 6 fatty acids) had a higher risk of substance abuse problems. Consumption of fish, fruits and vegetable and socio economic factors did not appear to be relevant.

Captain Hibbeln pointed out that our consumption of Omega 6 fatty acids, though our use of vegetable oils, shortenings and animal feed (all fed corn or soya), had increased from 5% to 30% of our diet and asked, therefore, whether it was not just sugar but fats that were affecting out brains?


The Role of food and diet in 'addictive' disorders

Dr Alex Richardson, Senior Research Fellow at the Centre for Evidence Based Intervention, University of Oxford. Founder Director FABResearch

Many different psychological disorders are associated with addictive features, including neurodevelopmental conditions such as ADHD, autism, schizophrenia, anxiety and mood disorders. Substantial evidence shows that nutrition and diet can play a signifcant role in the etiology and management of these conditions, yet it is all but ignored in current professional practice.

Anxiety underlies most addictive behaviours.

Long chain Omega 3 fatty acids are biologically useful and are essential for brain function: DHA for brain structure; EPA for signalling, blood flow and as an anti-inflammatory. Omega 3s affect control mechanisms and dopamine pathways. The ideal percentage of EPA for a child is 8–12% but a standard Western child gets only 2.46%.

Studies suggest that Omega 3s are helpful in the prevention of psychosis, schizophrenia (in one case episodes were reduced to one every 12 months) and depression. (1 gram a day apppears to be helpful for depression; 500mg are plenty for the general population although it is always better to get the nutrients from food eg fish, if possible.)

Addiction and substance abuse is the single biggest contributor to mental ill health. There are known to be addictive opiods and peptides in dairy products and gluten so could food cravings in food allergy and intolerance be related to an addictive pathway?


Addicted to antisocial behaviour.

Dr Bernard Gesch FRSA, Department if Physiology and Genetics, University of Oxford.

Criminal justice assumes that the criminal exercises free will when he/she commits a crime. It is impossible to exercise free will without using the brain to assess the situation and make a rational decision as to what action you will take. But if the brain is poorly nourished, how can it work properly and take rational and well balanced decisions?

(Within the criminal justice system itself it is recognised that decision making is related to our ability to metabolise energy in the brain. For example, the severity of sentencing has been shown to correlate with how long it was since the judge's last refreshment break.)

Social factors are extremely relevant in criminal behaviour but so is poor nutrition but while the former is very visible, the latter is not and is therefore ignored.

For 200 years we have been experimenting with our diets but at no point has there been any examination of what effect these experiments might have, or have had, on the brain.

Points of relevance:

• 2006. The WHO recognised that good nutritional status could be connected with a reduction in violent behaviour.

• The reduction in lead contamination worldwide between 1964 and 2004 is now accepted as crucial in the dramatic crop in violent crime worldwide during those years.

• Lead is known to be a potent nutrient antagonist pushing out calcium and iron and reducing brain size.

• Malnutrition in pregnancy affects the foetus, as was shown in the subsequent aggression levels shown my the children of mothers who suffered the Dutch 'hunger winter' during WWII.

• The exercise of will power is very energy expensive. There is a strong link between offending and hyploglycaemia (low blood sugar).

• 9 out of 13 young offenders have vitamin and mineral levels below the Lower Reference Nutrient Intakes

• Criminals rarely look healthy. Indeed many show signs of conditions such as scurvy and pellagra, both severe deficiency syndromes.

• US studies have shown a 34% reduction in violence between the active and placebo groups on nutritional supplementation. Similar studies in the UK showed a 24% reduction, in Holland a 34% reduction. None of these studies used mega doses of vitamins, merely the recommended daily amounts – and did not include any dietary manipulation.

• The nutritional approach ignores, colour, creed, background and circumstances; it is applicable to everyone.


Psychosis and addiction: Nutritional interventions in Mental Health

Kevin Williamson, Senior Nutritionist, Rotherham Early Intervention Psychosis team, Doncaster and South Humber Healthcare Trust

Following on from Professor Malcolm Peet's work in Rotherham, Kevin Williamson's team offer nutritional assessment and support as part of their routine care to clients suffering their first episode of psychosis – basing their interventions on the convincing evidence of the connection between the nutrients we consume and the way we think, feel and behave. This nutritional intervention is delivered along with medication and psychological and social interventions as appropriate.

Although NICE Guidelines for the treatment of both alcohol abuse and psychosis (there is a long established connection between the two) do not mention food or nutrition, schizophrenic patients consume more caffeine, higher levels of fat and sugar and smoke more.

The Rotherham service interventions involve:
• 4 x 24 hours recall dietary and nutritional assessments
• Dietary suggestions tailored to the individual client's nutritional needs
• Nutritional supplements – Omega 3s plus vitamins and minerals
• Supported shopping
• Participation in cooking and healthy living skills groups

Kevin then described two cases in one of which their intervention had been successful, in the other of which it had not! To take the latter first:

1. 23-year-old male who had suffered trauma and physical abuse and who was a heavy substance user.
His diet over one 24 hour period consisted of:
- 2 pizzas
- 27 packets of crisps
- 1 litre of Coke plus two more bottles for dinner
- 2 packs Jaffa cakes
- Skittles
- cereal bars
- 2 milk chocolate bars
- 4 large mugs instant coffee

Giving him a total of 529g sugar, 356g of fat, 36g salt and 840mg caffeine.

He refused to consider any dietary change....

2. 37-year-old male, suffering his first episode of psychosis. He did not sleep and was a substance abuser.

He was consuming 70–80g of fat per day and around 2,000 calories per day but no fish.
His major dietary change was to increase his intake of fish, fruit and vegetables.
He is now studying to become and plumber/builder.
He said:
'I have more energy. Occasionally I eat what I used to but it just makes me feel more anxious. I would advise anyone to eat fruit and vegetables, drink plenty of water and get involved in groups and socialise.'


July 2014


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