TYPE Original Research PUBLISHED 20 October 2022 DOI 10.3389/fpsyt.2022.1032150 Food addiction in Bulimia OPEN ACCESS Nervosa: Analysis of body EDITED BY Hubertus Himmerich, King’s College London, composition, psychological and United Kingdom REVIEWED BY problematic foods profile Monica Rose Leslie, University of Chester, United Kingdom Elena Tenconi, Lucero Munguía1,2,3† , Lucía Camacho-Barcia1,2,3† , University of Padua, Italy Anahí Gaspar-Pérez1,2 , Roser Granero2,3,4 , Carla Galiana2 , *CORRESPONDENCE Fernando Fernández-Aranda Susana Jiménez-Murcia1,2,3,5 , Carlos Dieguez3,6 , ffernandez@bellvitgehospital.cat Ashley Nicole Gearhardt7 and † These authors have contributed Fernando Fernández-Aranda1,2,3,5* equally to this work and share first authorship 1 Department of Psychiatry, University Hospital of Bellvitge, Barcelona, Spain, 2 Psychoneurobiology of Eating and Addictive Behaviors Group, Neurosciences Program, Bellvitge Biomedical Research SPECIALTY SECTION Institute (IDIBELL), Barcelona, Spain, 3 CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), This article was submitted to Instituto de Salud Carlos III, Barcelona, Spain, 4 Department of Psychobiology and Methodology, Psychological Therapy Autonomous University of Barcelona, Barcelona, Spain, 5 Department of Clinical Sciences, School and Psychosomatics, of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain, 6 Department a section of the journal of Physiology, Centro Singular de Investigación en Medicina Molecular y Enfermedades Crónicas Frontiers in Psychiatry (CIMUS), Instituto de Investigación Sanitaria, University of Santiago de Compostela, Santiago RECEIVED 30 August 2022 de Compostela, Spain, 7 Department of Psychology, University of Michigan, Ann Arbor, MI, ACCEPTED 06 October 2022 United States PUBLISHED 20 October 2022 CITATION Munguía L, Camacho-Barcia L, Gaspar-Pérez A, Granero R, Galiana C, Jiménez-Murcia S, Dieguez C, Introduction: Food Addiction (FA) has been related with eating disorders Gearhardt AN and (ED), especially Bulimia Nervosa (BN). BN + FA may have different physical Fernández-Aranda F (2022) Food characteristics than patients with BN without the comorbidity, such as addiction in Bulimia Nervosa: Analysis of body composition, psychological body mass index (BMI) or body composition, and psychological as emotion and problematic foods profile. regulation. However, the relationship between psychological and physical Front. Psychiatry 13:1032150. doi: 10.3389/fpsyt.2022.1032150 aspects, connected by problematic food and its influence on body COPYRIGHT composition, has been barely studied. Therefore, the aims of the present study © 2022 Munguía, Camacho-Barcia, are: Gaspar-Pérez, Granero, Galiana, Jiménez-Murcia, Dieguez, Gearhardt Aims: (a) To explore the differences in body composition between FA and Fernández-Aranda. This is an open-access article distributed under positive (FA+) and negative (FA–) in women with BN; (b) to identify the terms of the Creative Commons problematic relationship with certain food types, according with the foods Attribution License (CC BY). The use, mentioned in the YFAS scale questionnaire, between FA+ and FA– patients; distribution or reproduction in other forums is permitted, provided the (c) to know the psychological characteristic differences between FA+ original author(s) and the copyright and FA– patients, considering emotion regulation, personality traits and owner(s) are credited and that the original publication in this journal is general psychopathological state; (d) to identify the relationship between cited, in accordance with accepted physical and psychological traits, and the identified problematic foods, in academic practice. No use, distribution or reproduction is permitted which patients with BN and FA. does not comply with these terms. Methodology: N = 81 BN women patients, with a mean age of 29.73 years ± 9.80 SD, who completed the questionnaires: Yale Food Addiction Scale V 1.0 (YFAS 1.0), Eating Disorder Inventory-2 (EDI- 2), Symptom Checklist-90 Items-Revised (SCL-90-R), and Difficulties in Emotion Regulation Strategies (DERS). YFAS problematic foods were Frontiers in Psychiatry 01 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 grouped considering their principal nutrients sources. Body composition and difference in metabolic age was determined using bioimpedance analyzer. Results: The 88% of patients with BN presented FA+. Patients with BN who were FA+ self-reported more problematic relationships with sweets and starches. Also presented higher emotion regulation difficulties, general psychopathology and eating symptomatology severity, than those without FA. Finally, emotional regulation difficulties were positively associated with higher eating disorder symptomatology and more types of foods self-reported as problematic, which increased indirectly fat mass. Conclusion: The results suggest that BN + FA presented more eating and psychopathology symptomatology and higher problems with specific food types. As well, the path analysis emphasized that emotion regulation difficulties might be related with problematic food relationship in BN, impacting over the ED severity. Implications: The results may impact the development of precise therapies for patients with BN + FA. KEYWORDS food addiction, Bulimia Nervosa, emotion regulation, problematic foods, body composition Introduction (11). These results are consistent with other studies that have found that patients with BN + FA had worse prognosis than Food addiction (FA) has been described as the presence patients with BN without FA (2). of maladaptive eating behaviors consistent with addictive In BN, abnormal eating patterns and excessive processes, mainly characterized by excessive consumption of compensatory behaviors may result in alterations in body ultra-processed foods. While several studies have reported FA composition. It has been previously reported that patients in non-clinical samples (general adult population and student with bulimia had significantly higher total daily energy intake samples), the prevalence of FA is higher in populations with compared with control subjects (12). Further, certain groups of obesity, and in Eating Disorders (ED) patients, especially the women with BN consumed large meals primarily of desserts ones in the binge spectrum disorders, as Bulimia Nervosa (BN) and snack foods (13), which may contribute to higher BMI and (86–96%) (1–3). greater accumulation of adipose tissue. However, other study Frequently, in BN higher FA scores have been positively on body composition has found that normal weight patients associated with greater ED severity (4, 5), more general with BN display no significant differences in body composition psychopathology (5, 6) and greater dysfunctional personality when compared to healthy normal weight controls (14). traits (6, 7). Furthermore, Emotion Regulation (ER) difficulties Regarding the influence of FA on body composition, the and greater impulsivity seem to be an important characteristic evidence suggests that individuals with FA and obesity present in this population with absence of FA (FA–). Negative urgency higher weight and had greater total body fat and trunk has been found in the presence of FA (FA+) and binge spectrum fat than non-FA individuals (15), however, it has not been disorders patients (8, 9). Negative urgency represents the emotional-related aspect of impulsivity, indicating the tendency previously reported whether the presence of FA may play to act rashly and engage in problematic behavior (in the case of a role in the body composition of patients with BN. Even FA, the disorder eating patterns, and excessive food intake) as a though people with BN might present a normal weight in the response to a negative emotional state (10). majority of cases (16), the presence of comorbid FA could It is important to mention that recent studies have identified be affecting total body fat percentage. Previous studies have different subgroups of patients with ED and FA. Considering associated the excess accumulation of body fat in normal a cross-sectional and a longitudinal approach, Cluster-based weight individuals with adverse metabolic profiles, including analyses have found that FA is most commonly associated with dyslipidemias and cardiometabolic dysregulations (17–19). BN (relative to other types of disordered eating) (7, 11), which A more comprehensive clinical profile of BN + FA patients, predicts poorer treatment response, as higher rates of dropouts including psychological, nutritional and body composition Frontiers in Psychiatry 02 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 features, might be needed in order to establish a more first evaluation session, participants are informed that several personalized treatment approach for this group. research studies are carried out in the ED unit, and thought In order to explore this, is important to consider certain informed consent, they accepted the data of their evaluations foods as potentially addictive. Regarding FA model, this matter to be used with clinical and research purpose. Only participants is still under debate. Studies of non-ED patients have found that singed an informed consent were included in the study. that ultra-processed foods, high in refined carbohydrates and/or added fats are typically endorsed as the most addictive, but investigations into this topic in ED samples are limited (20, 21). Assessment Therefore, the present study has as aims: (a) to explore the differences in body composition between BN + FA and Psychometric measures BN-FA patients; (b) to identify problematic food relationships, Yale Food Addiction Scale V 1.0 (YFAS 1.0), (23); validated in according to the foods identified as most addictive on the YFAS, Spanish population (5). The YFAS questionnaire was validated between BN + FA and BN-FA; (c) to determine the clinical for a clinical population in 2009 and was subsequently validated differences in both groups, considering emotion regulation, in Spanish. YFAS is based on the criteria of the Diagnostic personality traits and general psychopathological state; (d) to and Statistical Manual of Mental Disorders, that measures identify the relationship between physical and psychological levels of substance dependence, where the term “substances” traits, and the considered problematic foods, in BN with FA is replaced by “certain food” and is used for the quantification patients, in order to determine a complete clinical profile in of the severity of FA during the previous 12 months. This this population. questionnaire assesses seven diagnostic criteria for dependence We hypothesize that those BN + FA patients, when in case of excessive consumption of high-fat and/or high-sugar compared to BN-FA, will present higher BMI and higher total foods. It uses two scoring systems: a count of FA symptoms body fat percentage, as well as worst general psychopathological (from 0 to 7, according to DSM-IV-TR diagnostic criteria) and state, higher severity of the disorder, and more emotional for the assessment of the diagnosis of FA (3 or more symptoms regulation difficulties. We also expect that the food referred with plus clinically significant impairment/distress). The measures a problematic relationship will be different between BN + FA consisted of 25 items answered on an 8-point Likert scale. The and BN-FA, where those patients with comorbid FA will internal consistency of the total scale for our sample was 0.820 report higher problematic associations to high fats and refined (coefficient alpha). carbohydrates food groups. Finally, that FA will not only Eating Disorders Inventory 2 (EDI-2) (24). Is reliable and be related with the psychological variables, contributing to a valid self-report questionnaire that assesses different cognitive general worst profile, as mentioned above, but will also have and behavioral characteristics typical of ED in eleven subscales: more problematic food relationships, as well as differences in the drive for thinness, bulimia, body dissatisfaction, inefficacy, body composition. perfectionism, interpersonal distrust, interoceptive awareness, fear of maturity, asceticism, impulse regulation, and social insecurity. The measures consist of 91 items, answered on a 6- Materials and methods point Likert scale. The internal consistency of the total scale for our sample was 0.955 (coefficient alpha). Sample and procedure Symptom Checklist-90-Revised (SCL-90-R) (25). The SCL-90-R questionnaire is used to assess a wide range of The present cross-sectional study was conducted in a sample psychological problems and symptoms of psychopathology composed of female outpatients diagnosed with BN (n = 81), considering nine primary symptom dimensions: somatization, with a mean age of 29.22 years ± 9.80 SD. Participants were obsessive-compulsive, interpersonal sensitivity, depression, recruited from the Eating Disorders Unit of the University anxiety, hostility, phobic anxiety, paranoid ideation, and Hospital of Bellvitge – Barcelona, who attended to request psychoticism; and includes three global indices: global severity treatment or were already linked to it, from 2013 to 2016. index (general psychological distress), positive symptom distress Diagnosis of BN was made by senior clinicians through a DSM-5 index (the intensity of symptoms), and a positive symptom total diagnostic criteria semi-structured clinical interview (SCID- (self-reported symptoms). The global severity index was used as 5) (22). Participants were evaluated trough a psychometric a test summary. The measure consists of 90 items answered on battery that included different questionnaires (see section a 5-point Likert scale. The internal consistency of the subscales “Psychometric measures”). All evaluations were performed by for our sample was 0.969 (coefficient alpha). experienced psychologists and psychiatrists. Difficulties in Emotion Regulation Scale (DERS) (26), In accordance with the Declaration of Helsinki, the validated in Spanish population (27).The DERS questionnaire present study was approved by the Clinical Research Ethics assesses emotion dysregulation in six subscales: non-acceptance Committee of the University Hospital of Bellvitge. During the of emotional responses, difficulties in pursuing goals when Frontiers in Psychiatry 03 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 experiencing strong emotions, difficulties in controlling with chi-square (χ2 ) tests for categorical measures and t-tests impulsive behaviors when experiencing negative emotions, lack for quantitative measures (exact p-values were obtained for of emotional awareness, limited access to emotional regulation proportion comparisons with expected counts lower than 5 strategies and lack of emotional clarity. The measure consists of and for mean comparisons with non-normal distribution). In 36 items and is answered on a 5-point Likert scale. The internal addition, these analyses included the calculation of the effect consistency of the subscales for our sample ranges between size through the standardized Cohen coefficient (h-value for 0.796 and 0.924, and the one for the total score was 0.950 proportion comparisons and d-value for mean comparisons, (coefficient alpha). considering the thresholds 0.50 and 0.80 for moderate and large effect size) (30). The association between the FA severity level Anthropometric parameters and body (YFAS total score) with body composition and other clinical composition measures was estimated with the correlation coefficients. Due Both height and weight were measured by trained personnel the solid association between the significance level for the and used to determine the body mass index (BMI), calculated R-coefficients and the sample size, effect size was considered as weight (Kg)/[height(m)]2 . Body composition was determined low-poor | R| > 0.10, moderate-medium for | R| > 0.24 and using the bioimpedance analysis, a practical, inexpensive, and large-high for | R| > 0.37 (31). non-invasive method, utilizing a Multifrequency TANITA MC- Path analysis was implemented through Structural Equation 80 body impedance device (TANITA, Japan). Values of total Modeling (SEM). All the parameters were free-estimated, and fat, non-fat, muscle and bone mass, as body water percentage a latent variable measuring the problematic foods profile was was analyzed. Basal metabolic rate and metabolic age (Met- defined based on the different foods analyzed in this work. With age) were determined by the device. Met-age was used to the aim to obtain a final parsimonious model (with the highest calculate difference in age (participants’ chronological age statistical power), parameters with not significant tests were minus participants Met-age). Metabolic age has been previously deleted and the model was re-specified and re-adjusted (only proposed as an indicator of inflammation and cardiovascular non-significant coefficients were retained for the measurement risk (28). parameters related to the latent variable). Goodness-of-fit was evaluated using standard statistical measures, and it was Problematic food groups considered adequate for (32): non-significant result in the χ2 To identify the problematic relationships generated by test, root mean square error of approximation RMSEA < 0.08, certain food groups, the last item of the YFAS questionnaire was Bentler’s Comparative Fit Index CFI > 0.90, Tucker-Lewis considered. This item presents a list of different foods so that Index TLI > 0.90, and standardized root mean square residual the participants can indicate those that him/her recognizes as SRMR < 0.10The global predictive capacity of the model was problematic. These foods were then grouped into five categories measured by the coefficient of determination (CD). according to the possible addicting nutritional content of their chemical composition: high in fat and simple sugars, high in fat and sodium, high in starch, high in simple sugars, and control Results foods (low in fat, sodium, starch, and simple sugars) (Table 1). Association of food addiction with problematic food groups, body Statistical analysis composition and clinical profile Statistical analysis was done with Stata17 for Windows The first block of Table 2 contains the distribution of all the (29). The comparison between the groups defined for the variables of the study among the total sample. The mean for BMI screening score in the YFAS (FA− versus FA+) was done was 24.2 kg/m2 (SD = 4.9). The problematic relationship with high fat/high sugars food was reported by 93.8% of the patients, TABLE 1 Distribution of the problematic foods included in YFAS. high fat/high sodium foods by 88.9%, high starches by 82.7% and Food groups Foods included in YFAS high sugars by 61.7%. Control foods were endorsed by 22.2%. Figure 1 displays the bar-charts with the distribution of High fat/High sugars ice cream, chocolate, cookies, cake, donuts the problematic food groups, for patients with and without High fat/High sodium bacon, burgers, pizza, French fries, steak, FA, according to the YFAS screening tool. Overall, patients cheeseburgers with a positive FA score increase the likelihood of recognize High starches white bread, pasta, rice, rolls as problematic all types of food, although only significant High in sugars candies, soft drinks differences were obtained for sweets with high fat content Controls apples, broccoli, lettuce, strawberries, carrots, (p = 0.034, | h| = 0.57) and starches (p = 0.022, | h| = 0.70). bananas However, the control foods were endorsed the least of all food Frontiers in Psychiatry 04 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 TABLE 2 Association between food addiction (FA) screening scores and clinical profile. Total (n = 81) FA − (n = 9) FA + (n = 72) Mean SD Mean SD Mean SD p |d| Fat mass 26.88 7.60 25.03 4.08 27.11 7.92 0.441 0.33 Non-fat mas 44.64 3.65 44.50 2.30 44.66 3.80 0.901 0.05 Muscle mass 42.62 3.50 42.45 2.25 42.64 3.64 0.880 0.06 Body water% 51.13 4.79 52.48 2.61 50.96 4.99 0.372 0.38 Bone mass 2.27 0.18 2.27 0.12 2.27 0.19 0.993 0.00 Basal metabolic rate 1369 123.0 1370 61.0 1369 128.9 0.975 0.01 Metabolic age 27.16 12.86 21.04 7.60 27.93 13.20 0.130 0.64† Difference in age 2.06 10.18 1.52 6.22 2.13 10.60 0.867 0.07 BMI (kg/m2 ) 24.18 4.88 23.16 1.63 24.30 5.13 0.513 0.30 EDI Drive thinness 15.21 4.51 11.56 4.45 15.67 4.33 0.009* 0.94† EDI Body dissatisfaction 17.27 7.38 14.56 6.35 17.61 7.47 0.244 0.44 EDI Interoceptive awareness 12.69 6.25 7.78 5.72 13.31 6.07 0.011* 0.94† EDI Bulimia 10.36 4.35 6.44 3.57 10.85 4.20 0.004* 1.13† EDI Interpersonal distrust 5.60 4.52 2.67 2.40 5.97 4.60 0.038* 0.90† EDI Ineffectiveness 12.06 6.69 9.56 4.98 12.38 6.84 0.236 0.47 EDI Maturity fears 7.94 4.59 8.00 2.92 7.93 4.78 0.966 0.02 EDI Perfectionism 6.38 4.56 3.78 2.28 6.71 4.68 0.069 0.80† EDI Impulse reg. 6.79 5.17 4.78 5.65 7.04 5.10 0.218 0.42 EDI Ascetic 7.94 4.04 5.00 2.60 8.31 4.05 0.020* 0.97† EDI Social insecurity 8.10 5.09 5.67 2.96 8.40 5.23 0.129 0.64† EDI Total 110.35 39.14 79.78 28.00 114.17 38.79 0.012* 1.02† SCL-90R Somatic 1.83 0.76 1.29 0.92 1.89 0.72 0.023* 0.73† SCL-90R Obs.-com 1.97 0.72 1.44 1.01 2.04 0.66 0.017* 0.71† SCL-90R Sensitivity 2.16 0.69 1.68 0.75 2.22 0.66 0.026* 0.76† SCL-90R Depress. 2.40 0.74 1.84 0.91 2.47 0.69 0.016* 0.77† SCL-90R Anxiety 1.62 0.69 1.16 0.83 1.67 0.66 0.034* 0.69† SCL-90R Hostility 1.22 0.78 0.72 0.52 1.28 0.79 0.041* 0.84† SCL-90R Phobic 0.97 0.66 0.80 0.72 0.99 0.66 0.433 0.27 SCL-90R Paranoia 1.45 0.72 1.23 0.92 1.48 0.69 0.328 0.31 SCL-90R Psychotic 1.34 0.55 1.20 0.68 1.36 0.54 0.408 0.27 SCL-90R GSI 1.79 0.56 1.37 0.78 1.84 0.52 0.017* 0.72† SCL-90R PST 65.16 12.73 57.78 21.12 66.08 11.16 0.065 0.51† SCL-90R PSDI 2.41 0.50 1.97 0.56 2.46 0.47 0.005* 0.94† DERS Non-acceptance 19.83 6.06 17.44 4.80 20.13 6.16 0.213 0.51† DERS Directed goals 17.30 4.69 16.67 4.06 17.38 4.78 0.672 0.16 DERS Impulse 18.15 4.81 15.56 2.96 18.47 4.92 0.087 0.72† DERS Awareness 17.23 4.05 18.44 2.01 17.08 4.22 0.345 0.41 DERS Strategy 26.37 6.65 23.44 5.22 26.74 6.74 0.163 0.55† DERS Lack of clarity 14.60 4.34 13.44 3.71 14.75 4.41 0.398 0.32 DERS Total 113.48 23.40 105.00 17.33 114.54 23.94 0.251 0.46 *Bold: significant comparison. † Bold: effect size into the mild to large range. groups and there were no differences between the FA+ and FA– (11.25% of the sample), relevant differences were considered groups (22.2% of individuals in both groups endorsed a problem for significant differences (p < 0.05) or effect size within with a control food). the ranges moderate to large (| d| > 0.50). No significant Table 2 contains the comparison of the body composition differences were observed in the body composition profile and clinical profile for women with BN and with FA+ between the FA+ and FA– groups. Women within the FA+ versus FA–. Due the low sample size for the FA− group group had a higher mean metabolic age, though no significant Frontiers in Psychiatry 05 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 FIGURE 1 Distribution of the self-reported problematic type of foods in patients with FA negative and positive score. differences were observed in the difference with chronological TABLE 3 Correlation matrix. age. The FA+ group also reported higher ED severity levels YFAS YFAS (EDI-2 drive for thinness, interoceptive awareness, bulimia, total total interpersonal distrust, perfectionism, ascetic, social insecurity Fat mass 0.289† SCL-90R Somatic 0.223 and total scales), worse psychology state (higher means in Non-fat mas 0.135 SCL-90R Obsessive- 0.217 all the SCL-90R scales, except for phobic anxiety, paranoid compulsive ideation and psychotic ideation), and worse performance in the Muscle mass 0.121 SCL-90R Sensitivity 0.365† emotion regulation (higher means in the DERS non-acceptance Body water% −0.299† SCL-90R Depression 0.338† of emotional responses, impulse control difficulties, and limited Bone mass 0.126 SCL-90R Anxiety 0.205 access to emotion regulation strategies). Basal metabolic rate 0.158 SCL-90R Hostility 0.215 Table 3 includes the correlation matrix to assess the Metabolic age 0.304† SCL-90R Phobic 0.136 relationship between the YFAS-total score (as a dimensional Difference in age −0.107 SCL-90R Paranoia 0.096 measure for the FA severity level) with body composition BMI (kg/m2 ) 0.226 SCL-90R Psychotic 0.134 and clinical profile. The YFAS-total was positively related with EDI Drive thinness 0.357† SCL-90R GSI 0.289† the total fat mass, metabolic age, the ED symptom severity EDI Body dissatisfaction 0.261† SCL-90R PST 0.258† levels as measured with the EDI-2 (except for ineffectiveness, EDI Interoceptive 0.323† SCL-90R PSDI 0.292† maturity fears, perfectionism, impulse regulation, and social awareness insecurity), the psychological distress as measured by the SCL- EDI Bulimia 0.377† DERS 0.204 90R (sensitivity, depression, and the global indexes), and the Non-acceptance difficulties in the emotional regulation (controlling impulsive EDI Interpersonal 0.274† DERS Directed goals 0.171 behaviors when experiencing negative emotions and limit access distrust to emotional regulation strategies). A negative correlation was EDI Ineffectiveness 0.135 DERS Impulse 0.246† also found between the YFAS-total and the percentage of body EDI Maturity fears 0.120 DERS Awareness − 0.056 water. EDI Perfectionism −0.030 DERS Strategy 0.244† EDI Impulse reg. 0.086 DERS Lack of clarity 0.115 EDI Ascetic 0.312† DERS Total 0.219 Path analysis EDI Social insecurity 0.189 EDI Total 0.317† Figure 2 shows the path-diagram with the standardized † Bold: effect size into the mild to large range. coefficients. Adequate goodness-of-fit was achieved [χ2 = 28.98 (p = 0.413), RMSEA = 0.021 (95% confidence interval: 0.001 to 0.080), CFI = 0.993, TLI = 0.989, and SRMR = 0.080]. The global predictive capacity was around 31% (CD = 0.306). In this study, the latent variable measuring the foods Supplementary Table 1 (Supplementary material) contains the profile was significantly defined by the observed variables sweets complete results for the SEM (tests for the total, direct and high fat, starches, and sweets (the coefficients for salty high indirect effects). fat and control foods obtained p < 0.05 values). Patients Frontiers in Psychiatry 06 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 FIGURE 2 Standardized coefficients in the path-analysis. FA: food addiction (0 = absent; 1 = present). Fit statistics: χ2 = 28.98 (p = 0.413); RMSEA = 0.021 (95%CI: 0.001 to 0.080); CFI = 0.993; TLI = 0.989; SRMR = 0.080; CD = 0.306. with more difficulties in the emotion dysregulation functions Our results, regarding the association of FA with specific obtained higher ED severity levels, worse psychopathology state, problematic food groups, showed that those patients with BN and higher scores in the latent variable measuring the foods and FA+ significantly recognize high sugars foods, high fat consumption profile. Women with FA + screening score also content foods and starches as problematic. These findings greater ED severity level and higher psychological distress. The are consistent with data obtained in a study that aimed higher fat mass levels were directly predicted by higher scores in to explored the differences in dietary preferences, through the EDI-2 total. The ED severity level was also implied in some the dietary intake, among an adult population with and indirect relationships: (a) higher scores in the DERS total and without FA (33). Their results regarding dietary behavior being in the FA+ group impacted in the EDI-2 total score, which showed that a significantly higher proportion of people with next contributed to the increase in the fat mass; and (b) higher FA+ reported higher intakes of high fat foods, such as scores in the latent variable measuring the foods consumption snacks, fast food and chips, as well as greater intake of profile were associated with increased levels in the EDI-2 total, soft drinks, rich in sugars (33). This is also consistent with which next contributed on the fat mass. studies in non-clinical samples that find that foods with high levels of refined carbohydrates and/or added fats are indicated as the most addictive (20, 21). This is relevant Discussion to the current debate about whether the attributes of the food are an important factor in triggering addictive processes The aims of the present study were to explore differences or whether the act of eating (regardless of food type) is in body composition and psychological characteristics between more important (34). The current findings are consistent BN with and without FA, whether there were differences in the with the hypothesis that certain foods are more likely to self-reported problematic relationship with the different food be implicated in addictive patterns of intake, specifically types evaluated with the YFAS; and finally, in BN + FA patients, processed foods with high levels of reinforcing ingredients (e.g., to identify the relationship between physical and psychological sugar, starches, fat). traits, and the food type considered problematic. Regarding the psychological characteristics, the present The majority of patients with BN endorsed FA (88.75%), results were coincident with the literature in reference to a worst which highlights the importance of investigating addictive psychopathological general state, and, specially, more difficulties mechanisms in this population (1, 6, 7). Despite the relatively in ER, in BN + FA, when compared to BN-FA [T. (7–9, 11, small number of patients with BN who did not endorse FA, 35)]. As well, the FA + groups presented higher ED severity; differences between those with and without FA still emerged. current literature have reported that FA was associated with Frontiers in Psychiatry 07 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 more craving and binge episodes in BN (36). According to Limitations and future research lines the FA model, this could be related with the type of foods that are consumed. In both, animals and human based studies, This study has a few limitations. Firstly, due to the cross- the consumption of high palatable foods and with a high sectional design of the study causality cannot be conferred. glycemic load generate changes in the hunger and reward Secondly, our cohort consisted of young women adults with BN, circuits (37–39). Current reviews have gone deeper into the further studies would be required focusing on both sexes and study of how the addictive process can be activated by certain wider age range including postmenopausal women and, finally, types of food in similar ways as in other addictive substances. the low sample size of the BN-FA group that may compromise They concluded that high palatable food could induced changes the generalization of the results. in the hedonic system resulting in craving for the substance However, an interesting research line could be open (positive reinforcement), while tolerance is developed, and the based on the current results. To our knowledge, there are desire of further activation increases as well, in order to avoid few studies exploring the relationship between BN, FA, and the negative effect of the non-consumption of the substance body composition parameters that suggest the important (negative reinforcement) (40). relevance of ER processes. Empirically supported treatments Considering body composition, although BN + FA showed for addiction commonly focus on helping individuals develop quasi-significant greater levels of fat mass and mean BMI, ER strategies (48), therefore, investigating whether targeted contrary to our hypothesis, those results were not statistically interventions for ER could also improve treatment outcomes significant, when compared with BN-FA. Even though we for BN + FA individuals is an important next step to expected to find dissimilarities when compared the FA+ and explore. Further, the high endorsement rate of problems with foods types that are hypothesized to be more addictive FA– groups, these results are consistent with that of Probst et al. (e.g., high fat sweets) suggests that future research is needed (14) who concluded that BN women patients did not display to understand the role of the food triggering addictive differences in the body composition profile when compared to eating and foresee treatment outcome for individuals with healthy controls (14). These may be due to our study small eating disorders. sample size, and further studies with a bigger cohort are needed to confirm them. Finally, the path analysis that explores the associations of FA, psychological traits, and fat mass, show interesting results. The Data availability statement presence of FA, and the higher scores in the DERS total, both The datasets presented in this article are not readily available had an impact in the EDI-2 total score, which then contributed because of the protection law for the anonymized data of public indirectly to the increased fat mass. This result could support hospital patients in Spain. Requests to access the datasets should the multicausality and multifunctionality of eating disorders, be directed to FF-A, ffernandez@bellvitgehospital.cat. and the justification of biopsychosocial explanatory models, as has been suggested in previous studies (41). As well, these results open an important research line. We found that ER Ethics statement state was possible associated with the type of food considered problematic, which may be an introductory aspect to determine The studies involving human participants were a different BN + FA profile, highly influenced by ER difficulties, reviewed and approved by Clinical Research Ethics due to only indirect results have been explored in this field (2). Committee of the University Hospital of Bellvitge. The Previous studies have found that the mood influences in patients/participants provided their written informed consent the body idealization and dissatisfaction, besides the presence to participate in this study. of high caloric food cues (42), and that the negative emotions triggered the desire to eat and the selection of high caloric foods (43, 44). Other authors have found, in laboratory controlled Author contributions situations, that patients with FA increases their attention to food images after sad mood was induced (45). Therefore, LM, LC-B, SJ-M, and FF-A: conceptualization. RG: future studies, from a broader neurobiological perspective, methodology, formal analysis, and data curation. LM, LC-B, may analyze the underlying interaction of abnormal eating and AG-P: investigation. SJ-M and FF-A: resources. LM, LC-B, patterns and emotional regulation difficulties (46, 47) in BN, AG-P, SJ-M, RG, and FF-A: writing – original draft preparation. in order to confirm whether BN + FA patients, who have LM, SJ-M, AG, and FF-A: writing – review and editing. LM, higher ER difficulties, may be a different BN subtype. In SJ-M, CD, AG, and FF-A: supervision. SJ-M and FF-A: funding addition, measurement of specific neurobiological biomarkers acquisition. All authors have read and agreed to the published could improve the identification of specific subset of patients. version of the manuscript. Frontiers in Psychiatry 08 frontiersin.org Munguía et al. 10.3389/fpsyt.2022.1032150 Funding Conflict of interest This work was additionally supported by a grant from The authors declare that the research was conducted in the the Ministerio de Ciencia, Innovación y Universidades (grant absence of any commercial or financial relationships that could RTI2018-101837-B-100). This research was funded by the be construed as a potential conflict of interest. Delegación del Gobierno para el Plan Nacional sobre Drogas (2019I47 and 2021I031), and Fondo Investigación Sanitaria (FIS PI20/132), Instituto de Salud Carlos III (ISCIII) and Publisher’s note co-funded by FEDER funds/European Regional Development Fund (ERDF), a way to build Europe. CIBERObn is an All claims expressed in this article are solely those of the initiative of ISCIII. RG was supported by the Catalan Institution authors and do not necessarily represent those of their affiliated for Research and Advanced Studies (ICREA-Academia, 2021- organizations, or those of the publisher, the editors and the Programme). AG-P was supported by a pre-doctoral Grant of reviewers. Any product that may be evaluated in this article, or Fundación Carolina and the Secretaría de Relaciones Exteriores claim that may be made by its manufacturer, is not guaranteed de los Estados Unidos Mexicanos (Foreign relations secretary of or endorsed by the publisher. the United States of Mexico). Supplementary material Acknowledgments The Supplementary Material for this article can be We thank CERCA Programme/Generalitat de Catalunya for found online at: https://www.frontiersin.org/articles/10.3389/ institutional support. fpsyt.2022.1032150/full#supplementary-material References 1. De Vries SK, Meule A. Food addiction and bulimia nervosa: new data based 10. Whiteside SP, Lynam DR. The five factor model and impulsivity: using a on the yale food addiction scale 2.0. Eur Eat Disord Rev. (2016) 24:518–22. doi: structural model of personality to understand impulsivity. Pers Individ Differ. 10.1002/ERV.2470 (2001) 30:669–89. doi: 10.1016/S0191-8869(00)00064-7 2. 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