Preliminary validation of the Yale Food Addiction Scale for children☆,☆☆
Introduction
A growing body of evidence suggests that highly processed foods, or ingredients in these foods, may be capable of triggering an addictive process (Avena et al., 2008, Gearhardt, Davis et al., 2011). Animal models of addictive eating find that rats given access to sugar or highly processed foods exhibit classic behavioral and biological signs of addiction (e.g., withdrawal, tolerance, dopaminergic downgrading) (Avena et al., 2008, Johnson and Kenny, 2010). In adult humans, patterns of neural activation commonly implicated in addiction are also indicated in obesity (Volkow, Wang, Fowler, & Telang, 2008) and behavioral indicators of addiction such as loss of control over consumption and continued use despite negative consequences are also present in eating disorders (Gearhardt et al., 2009a, Gold et al., 2003). Although evidence is growing to support the concept of addictive-like eating among adults, little is known about the role it may play in childhood obesity. In the substance dependence literature, an earlier age of exposure to addictive substances (e.g., alcohol, nicotine) is implicated in risk for the development of problematic substance use in the future (DeWit, Adlaf, Offord, & Ogborne, 2000). This risk is thought to result from adaptations in a vulnerable neural system (Tapert, Caldwell, & Burke, 2005), as well as an increased likelihood of relying on substances to cope psychologically (Clark, Thatcher, & Tapert, 2008). If highly processed foods also have addictive potential, children may be more susceptible to this effect than adults due to neural and psychological vulnerabilities.
There is some evidence to suggest that addictive processes may be at play in problematic eating behavior in children. Central components of addiction (i.e., emotionally triggered use and binge consumption) (Berking et al., 2011, Naimi et al., 2003) are also factors in problematic eating. Emotional eating and binge eating are documented phenomena in adults (Arnow et al., 2006, Grilo et al., 2001), but evidence is growing that children (especially obese children) are prone to these tendencies as well (Shapiro et al., 2007, van Strien and Oosterveld, 2008). In a qualitative study of overweight/obese 8-to-21 year olds, behaviors consistent with addiction (e.g., tolerance, cravings) were frequently described and 66% identified addiction as a contributor to their eating problems (Pretlow, 2011). Additionally, 15.2% of children receiving treatment at a pediatric lipid clinic reported that they often felt addicted to food (Merlo, Klingman, Malasanos, & Silverstein, 2009). Children who answered affirmatively to more addiction-related eating questions were also more likely to indicate other eating-related issues (Merlo et al., 2009).
This evidence is consistent with an addictive process contributing to childhood obesity, but further examination of this concept is needed. To facilitate future work on the topic, a valid measure is needed to operationalize food addiction in children based upon substance dependence diagnostic criteria. Although there is no validated measure of food addiction in children, the Yale Food Addiction Scale (Gearhardt, Corbin, & Brownell, 2009b) is a validated measure of addictive-like eating behavior in adults based on the Diagnostic and Statistical Manual of Mental Disorder IV-Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) diagnostic criteria for substance dependence (see Table 1). Higher scores on the YFAS are associated with a more severe presentation of binge eating disorder (BED) (Gearhardt, White, et al., 2011) and food addiction (as assessed by the YFAS) is associated with a pattern of neural response during exposure to food cues and food consumption that is consistent with the neural activation associated with other addictive behaviors (Gearhardt, Yokum, et al., 2011). The current study seeks to develop a new version of the YFAS to assess symptoms of food addiction in children. The YFAS for children (YFAS-C) is designed to measure the degree to which the substance dependence criteria outlined in the DSM-IV (American Psychiatric Association, 2000) are relevant to the consumption of calorie-dense foods in children. We conduct a preliminary validation of the YFAS-C by examining the internal consistency of the measure, the convergence with other measures of eating behavior, and the incremental utility of the measure in predicting body mass index (BMI) above and beyond other measures of eating.
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Participants
This study was approved by the Yale Institutional Review Board. Parental guardians provided written informed consent and children provided verbal assent. A total of 117 children and their parents were recruited from the New Haven community for a larger study on family dining preferences and eating habits. The parents of the children participating in the study were 65.1% (n = 47) Caucasian, 25.7% (n = 18) African-American, 2.9% (n = 2) Hispanic and 4.3% (n = 3) of other race/ethnicity. A subset of 75
Establishment of scoring thresholds
Thresholds for the continuous questions in the adult YFAS were used as starting points to establish cut-offs for the YFAS-C. To evaluate whether the cut-offs accurately identified increased risk for eating pathology, scatter plots were created to explore the relation between YFAS-C questions and BMI. Of the 25 questions on the YFAS-C, three were altered from the scoring thresholds used in the adult YFAS. Additionally one question with a dichotomous scoring option from the adult version was
Discussion
The goal of the current study was to conduct a preliminary evaluation of a measure to operationalize addictive-like eating behavior in children and to examine the association of this scale with other measures of problematic eating. A CFA provided support for a single factor for the YFAS-C and demonstrated adequate internal consistency when the 22 items comprising the 7 diagnostic criteria were evaluated (Bentler, 1990, Browne and Cudek, 1993). The relatively lower internal consistency when the
Conclusion
The current study provides preliminary evidence that the YFAS-C is a reliable and valid tool to operationalize food addiction in children. This measure provides a definition of addictive eating that is consistent with the diagnostic criteria for substance dependence, thus increasing the likelihood of identifying a similar process. Further, preliminary analyses suggest that the measure exhibits adequate internal consistency, as well as convergent and incremental validity. The YFAS-C provides an
Role of funding sources
During this work, Christina Roberto was supported by the National Institute of Diabetes and Digestive and Kidney Diseases grant 1F31DK088523-01. The funding source had no involvement in the interpretation of the data, writing of the report, and in the decision to submit the manuscript.
Contributors
Ashley N. Gearhardt: Dr. Gearhardt developed the YFAS-C, conducted analyses, drafted the initial manuscript and approved the final manuscript as submitted.
Christina A. Roberto: Dr. Roberto designed the study, supervised data collection, critically evaluated initial drafts, and approved the final manuscript as submitted.
Marissa J. Seamans: Ms. Seamans coordinated data collection, critically evaluated initial drafts and approved the final manuscript as submitted.
William R. Corbin: Dr. Corbin
Conflict of interest
All authors declare that they have no conflicts of interest.
References (34)
- et al.
Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake
Neuroscience and Biobehavioral Reviews
(2008) - et al.
Effects of perinatal exposure to palatable diets on body weight and sensitivity to drugs of abuse in rats
Physiology & Behavior
(2012) - et al.
Measuring behavioural susceptibility to obesity: Validation of the child eating behaviour questionnaire
Appetite
(2007) - et al.
Preliminary validation of the Yale Food Addiction Scale
Appetite
(2009) Diagnostic and statistical manual of mental disorders
(2000)- et al.
The emotional eating scale: The development of a measure to assess coping with negative affect by eating
International Journal of Eating Disorders
(2006) Comparative fit indexes in structural models
Psychological Bulletin
(1990)- et al.
Deficits in emotion-regulation skills predict alcohol use during and after cognitive–behavioral therapy for alcohol dependence
Journal of Consulting and Clinical Psychology
(2011) CDC growth charts: United States
Alcohol, psychological dysregulation, and adolescent brain development
Alcoholism, Clinical and Experimental Research
Age at first alcohol use: A risk factor for the development of alcohol disorders
The American Journal of Psychiatry
Food addiction: An examination of the diagnostic criteria for dependence
Journal of Addiction Medicine
The addiction potential of hyperpalatable foods
Current Drug Abuse Reviews
An examination of the food addiction construct in obese patients with binge eating disorder
International Journal of Eating Disorders
Neural correlates of food addiction
Archives of General Psychiatry
Overeating, binge eating, and eating disorders as addictions
Psychiatric Annals
Cited by (0)
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Funding: During this work, Christina Roberto was supported by the National Institute of Diabetes and Digestive and Kidney Diseases grant 1F31DK088523-01.
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Financial disclosure: The authors have no financial disclosures to report.