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Nutritional Neuroscience
An International Journal on Nutrition, Diet and Nervous System
ISSN: 1028-415X (Print) 1476-8305 (Online) Journal homepage: http://www.tandfonline.com/loi/ynns20
Assessment of the relationship between food
addiction and nutritional status in schizophrenic
patients
Özge Küçükerdönmez, Murat Urhan, Merve Altın, Özge Hacıraifoğlu & Burak
Yıldız
To cite this article: Özge Küçükerdönmez, Murat Urhan, Merve Altın, Özge Hacıraifoğlu & Burak
Yıldız (2017): Assessment of the relationship between food addiction and nutritional status in
schizophrenic patients, Nutritional Neuroscience, DOI: 10.1080/1028415X.2017.1392429
To link to this article: http://dx.doi.org/10.1080/1028415X.2017.1392429
Published online: 27 Oct 2017.
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Download by: [Chalmers University of Technology]
Date: 29 October 2017, At: 00:45
Assessment of the relationship between food
addiction and nutritional status in
schizophrenic patients
Özge Küçükerdönmez1, Murat Urhan2, Merve Altın3, Özge Hacıraifoğ lu3,
Burak Yıldız3
Faculty of Health Sciences, Department of Nutrition and Dietetics, Ege University, İ zmir, Turkey, 2Mental
Health and Diseases Hospital, Manisa, Turkey, 3Izmir Atatürk School of Health, Department of Nutrition and
Dietetics, Ege University, Izmir, Turkey
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1
Objective: Obesity is one of today’s most important public health problems. It is suggested that overeating
and substance addiction show similarities, and addiction to food may be an important factor in the obesity
epidemic. This study aimed to determine the prevalence of food addiction among schizophrenic patients
and to examine the relationship between food addiction and anthropometric measurements and dietary
nutrient intake.
Methods: Study participants included a total of 104 schizophrenic outpatients, 62 females and 42 males.
Food addiction was assessed by using the Yale Food Addiction Scale, and the anthropometric
measurements of participants and their three-day food consumption were recorded.
Results: This study found that more than half of the schizophrenic patients (60.6%) had food addiction, and
that female schizophrenic patients had a higher prevalence (62.9%) of food addiction than male patients
(57.1%). More than one-third of the schizophrenic patients with food addiction (41.3%) were found to be
obese and their BMI, body weight, waist circumference, and body–fat ratio were higher than those of
schizophrenic patients who did not have food addiction (P > 0.05). Moreover, the schizophrenic patients
with food addiction were found to take significantly more energy, carbohydrate, and fat in their diet (P < 0.05).
Conclusion: It was observed that the development of food addiction in schizophrenic patients increased the
risk of obesity and cardiovascular diseases, which were found to be at higher levels in these patients.
Educational programs should be planned for these patients to acquire health dietary habits and to
increase their physical activity levels, and an additional psychosocial support should be provided for
patients with food addiction.
Keywords: Food addiction, Schizophrenia, Obesity, Yale food addiction scale, Nutrition
Introduction
Schizophrenia is a severe psychiatric disorder which
causes substantial disability and has a profound
effect on individuals and society.1 Schizophrenic
patients are known to have increased morbidity and
mortality rates in comparison with the general population, and their life expectancy is approximately
20% shorter than that of healthy individuals.2 This is
explained by the high prevalence of metabolic syndrome found in these patients, which includes cardiovascular risk factors such as impaired glucose and
insulin metabolism, hypertension, atherogenic dyslipidemia, and central obesity.3 Studies showed that the
rate of obesity in schizophrenic patients is two to
Correspondence to: Özge Küçükerdönmez Faculty of Health Sciences,
Department of Nutrition and Dietetics, Ege University, Bornova 35040,
İzmir, Turkey. Email: dytozgek@hotmail.com
© 2017 Informa UK Limited, trading as Taylor & Francis Group
DOI 10.1080/1028415X.2017.1392429
three times greater than in the general population
and 45–55% of the patients are obese.4–7 Poor eating
habits, sedentary lifestyle, genetic predisposition, and
atypical antipsychotics used in schizophrenia treatment, especially clozapine and olanzapine, are the
foundation for the increase in the rate of obesity in
schizophrenic patients.4,8–10
The theory of food addiction has seen increasing
popularity as a concept in recent years. This theory
suggests that some processed foods ( pizza, chocolate,
sugary beverages etc.) can cause addiction and that
obesity and eating disorders are the results of a
response that causes addiction to these foods.11
However, while behavioural problems such as gambling addiction are recognized by the American
Psychiatric Association, there has been no universally
accepted definition for food addiction.12–14
Nutritional Neuroscience
2017
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Küçükerdönmez et al.
Food addiction and nutritional status
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Studies in people and animals have found that processed foods and the components of these foods (e.g.
sugar) may trigger behavioural (e.g. the continuation
of use in spite of negative consequences) and biological
(e.g. dopamine downregulation) processes observed in
substance-addicted individuals. Moreover, studies
have shown that food addiction is closely associated
with the dysfunctions of brain-reward system.15–17
Neuroimaging studies conducted with schizophrenic
patients have found structural and functional impairments in the cortical regions, including orbitofrontal,
medial dorsolateral prefrontal, and cingulate cortices,
and subcortical brain areas, such as ventral striatum,
thalamus, amygdala, and hippocampus functioning,
in the reward process. Studies have also found that
dopaminergic dysfunction in these patients leads to
abnormal reward processes and plays an important
role in the pathophysiology of schizophrenia.18–20
Weight increase is one of the most serious sideeffects of the antipsychotic drugs that have an important place in the treatment of schizophrenia. A study
suggested that the antagonistic effect of antipsychotics
on dopamine is responsible for the increase in food
intake.21 A study conducted by Amani et al.22 found
that schizophrenic patients preferred products containing whole-fat cream and sugary beverages in their
daily diet more than healthy individuals did.
Another study reported that individuals using clozapine consumed approximately twice as much sugar
as individuals using other antipsychotics, and that
there was a negative relationship between psychiatric
symptoms and sugar consumption.23 Studies in schizophrenic patients found that these individuals had poor
dietary habits, and consumed more foods containing
saturated fat and sugar in their daily diet than
healthy individuals, while their fiber and fruit consumption levels were lower.3,24–26
This study aimed to determine the prevalence of
food addiction among schizophrenic patients and to
assess whether there is a difference between individuals
with food addiction and those without it in terms of
their nutritional status and anthropometric
measurements.
Material and method
Participants
This study included a total of 104 schizophrenic outpatients, including 62 females and 42 males, who were
aged between 20 and 60 and diagnosed with schizophrenia according to the DSM-5 diagnostic criteria
in the Psychiatric Polyclinic of the Mental Health
and Diseases Hospital (Manisa, Turkey). Approvals
were received from treating doctors for these individuals to be included in the present study. Those who
were pregnant, who had alcohol and/or substance
abuse (except for nicotine), and who had neurological
2
Nutritional Neuroscience
2017
diseases were not included in the study. All participants were informed about the study and voluntarily
agreed to participate and written consents were
obtained. The Ethical Committee Report for this
study was obtained from the Clinical Research
Ethics Committee of Ege University School of
Medicine (İzmir, Türkiye). Sociodemographic data
including age, sex, marital status, educational level,
working status, smoking, and medications used for
treatment were collected from all participants using
the face-to-face interview method.
The number of subjects of monotherapy is 67, while
the number of subjects of polypharmacy (using two or
more antipsychotic agents) is 37. The subjects of
monopharmacy were receiving olanzapine (n = 30),
quetiapine (n = 14), risperidone (n = 12), aripiprazole
(n = 7) and, haloperidol (n = 4).
Anthropometric measurements
BMI was calculated using the formula, ‘weight (kg)/
body height2 (m).’ The assessment of BMI was conducted using the WHO classification. According to
this classification, BMI less than 18.5 kg/m2 is
regarded as underweight, BMI ranging from 18.5
to 24.9 kg/m2 is regarded as normal, BMI ranging
from 25.0 to 29.9 kg/m2 is regarded as overweight,
BMI equal to and higher than 30.0 kg/m2 is
regarded as obese.27 The body height of participants
was measured by using Seca stadiometer (Seca mod.
240 CE 0123, Germany) with a 0.1 cm margin of
error. Participants’ body weight, body-fat mass, fatfree body mass, body water percentage, and bodyfat percentage were measured using the Tanita BC532 bioelectrical impedance device with the participant wearing light clothes and after fasting for
eight hours. The waist circumferences of participants
were measured finding the midpoint between the last
rib and the top of the iliac crest on the bare skin.
The hip circumferences of participants were
measured over their clothes and 1 cm was deducted
from the measurement for the thickness of clothes.
The hip circumferences of participants were
measured from the top point. The waist-to-hip ratio
was calculated by dividing the value of waist circumference by the value of the hip circumference.27 The
waist to height ratio was obtained by dividing the
value of waist circumference by the value of body
height.28
The assessment of nutritional status
The three-day food consumption of participants was
recorded. Their average daily dietary intake of
energy, macro- and micronutrients was calculated
using the Nutrition Information Systems Package
Program (BEBIS).
Küçükerdönmez et al.
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Yale food addiction scale (YFAS)
The YFAS is a 25-item self-reporting questionnaire,
which was developed to diagnose behavioural food
addiction over the past 12 months and determine its
sub-criteria.29 The scale was developed by considering
the substance addiction diagnostic criteria of the
Diagnostic and Statistical Manual of Mental
Disorders-IV (DSM-IV). The scale is scored by the
counting of symptoms ranging from 0 and 7, which
indicate the number of addiction symptoms (e.g. consuming more than intended, persistent desire or
repeated unsuccessful attempts to quit, spending
much time to obtain, use, recover, giving up other
important activities, continuing to use despite physical
and psychological problems, tolerance, and withdrawal). For the diagnosis of food addiction, there must
be clinically significant impairment, plus meeting at
least three of seven diagnostic criteria in the past
twelve months.30,31
Food addiction and nutritional status
mean age of participants was found to be 39.4 ±
10.78 years. More than half of the participants
(60.6%) were found to have food addiction, while
39.4% were found not to have food addiction (P >
0.05). Nearly two-thirds of the female schizophrenic
patients (62.9%) and more than half (57.1%) of the
male schizophrenic patients were found to have food
addiction (P > 0.05). This study found that 82.7% of
the participants were not working, 23.8% of those
with food addiction, and 9.8% of those not having
food addiction were working. The number of symptoms in the participants with food addiction was
found to be 4.5 ± 1.20, while it was found to be 1.63
± 0.62 in those who did not have food addiction
(P < 0.01) (Table 1). Among the ones who were
using Olanzapin 53.3% were food addicted whereas
among Ketiyapin users it was 57.1%. For aripiprazol
the ratio was 71.4%, for risperidon it was 83.3%, and
the ones who used Haloperidol were totally food
addicted.
Statistical analyses
The qualitative data obtained from the participants
were analyzed using number (N) and percentage (%),
and the chi-square test was used to examine the
relationship between categorical variables. The mean
(
x) and standard deviation (SD) values of quantitative
data were obtained, and the differences between
groups were assessed using the independent samples
t-test for parametric data. P < 0.05 was considered evidence of statistical significance. All of the analyses
were performed using SPSS 22.0 package program.
Results
General characteristics and food addiction
prevalence in the participants
A total of 104 schizophrenic outpatients, including 62
females and 42 males participated in this study. The
The distribution of participants with food
addiction according to BMI
Of the schizophrenic patients who had food addiction,
41.3 and 33.3% were found to be obese and slightly
overweight, respectively; whereas 22 and 39% of the
participants who did not have food addiction, were
found to be obese and slightly overweight, respectively.
Only 1.6% of the participants who had addiction were
found to be underweight, while 23.8% were found to
have normal weight. The BMI was found to be
higher than 25 kg/m2 in 69.3% of the entire group
and in 61% of those who did not have food addiction,
while this was found to be 74.6% in the participants
with food addiction (Fig. 1).
Table 1 General characteristics of the participants
Food addiction
Characteristics
Age (year)
Sex
Entire group
Female
Male
Employment status
Full time
Not employed
Number of symptoms
Medications
Olanzapine
Quetiapine
Risperidone
Aripiprazole
Haloperidol
Polypharmacy
Entire sample (n = 104)
Yes (n = 63)
No (n = 41)
P*
39.4 ± 10.78
39.5 ± 10.83
39.2 ± 10.83
0.903
104 (100.0%)
62 (60.8%)
42 (39.2%)
63 (60.6%)
39 (62.9%)
24 (57.1%)
41 (39.4%)
23 (37.1%)
18 (42.9%)
0.349
19 (18.3%)
85 (82.7%)
3.5 ± 1.73
15 (23.8%)
48 (76.2%)
4.5 ± 1.20
4 (9.8%)
37 (91.2%)
1.63 ± 0.62
0.057
30 (29.9%)
14 (13.5%)
12 (11.5%)
7 (6.7%)
4 (3.9%)
37 (35.6%)
16 (53.3%)
8 (57.1%)
10 (83.3%)
5 (71.4%)
4 (100%)
20 (54.1%)
14 (46.7%)
6 (42.9%)
2 (16.7%)
2 (28.6%)
–
17 (45.9%)
0.225
0.001*
*Chi-square test; comparision of food addiction Yes/No; bold indicates significance.
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2017
3
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Küçükerdönmez et al.
Food addiction and nutritional status
Figure 1 The distribution of BMI values of participants according to YFAS.
(82.5%), which was followed by ‘persistent desire or
repeated unsuccessful attempts to quit’ (77.8%).
‘Social, occupational, or recreational activities given
up or reduced’ was the least reported symptom
(28.6%), and other symptoms were found to be
higher than 60%. More than half of the participants
who did not have food addiction (51.2%) stated that
they experienced ‘Persistent desire or repeated unsuccessful attempts to quit’ (Table 3).
Anthropometric measurements
The body weight and BMI values of participants with
food addiction were found to be higher than those of
participants without food addiction. However, no significant difference was found between the participants
with food addiction and those not having food addiction (P > 0.05). The BMI value was found to be 29.25
± 5.89 kg/m2 in the patients with food addiction and
27.4 ± 6.39 kg/m2 in those who did not have food
addiction. Similarly, the waist circumference, hip circumference, and body-fat percentage of the participants with food addiction were found to be higher
than those of participants who did not have food
addiction (P > 0.05). The body-fat percentage was
found to be 32.3 ± 9.23% in participants with food
addiction and 30.1 ± 9.80% in those without food
addiction. No difference was found between the
groups in terms of waist-to-hip ratio, waist-to-height
ratio, and fat-free body mass (P > 0.05) (Table 2).
Assessment of participants’ energy and dietary
intake
The dietary energy intake of schizophrenic patients
with food addiction, was found to be significantly
higher than in those who did not have food addiction
(P < 0.01). This study found that the participants who
had food addiction had a daily dietary intake of 2535
± 887.90 kcal/day, while those who did not have
food addiction consumed 1994 ± 700.96 kcal/day
(Table 4). Moreover, the dietary carbohydrate, fiber,
fat, and polyunsaturated fatty acid intakes of the
schizophrenic patients with food addiction, were
found to be significantly higher than in those who
did not have food addiction (P < 0.05; P < 0.01).
Endorsement rates of YFAS symptoms
The participants who had food addiction were found
to experience problems mostly because of ‘continued
use despite knowledge of adverse consequences’
Table 2
Anthropometric characteristics of participants according to the diagnosis of food addiction (
x ± SD)
Food addiction
Characteristics
Body weight (kg)
BMI (kg/m2)
Body height (cm)
Waist circumference (cm)
Hip circumference (cm)
Waist-to-hip ratio
Waist-to-height ratio
Neck circumference (cm)
Body fat percentage (%)
Fat-free body mass (kg)
Entire sample (n = 104)
Yes (n = 63)
No (n = 41)
Bottom–top
P*
79.5 ± 18.70
28.5 ± 6.13
167.2 ± 9.37
95.5 ± 15.83
105.6 ± 10.94
0.9 ± 0.10
0.6 ± 0.10
36.6 ± 4.28
31.4 ± 9.55
50.5 ± 8.82
81.5 ± 19.04
29.2 ± 5.89
167.1 ± 10.62
96.4 ± 15.44
107.2 ± 11.42
0.9 ± 0.09
0.6 ± 0.10
36.5 ± 3.97
32.3 ± 9.23
50.8 ± 8.98
76.5 ± 17.97
27.4 ± 6.39
167.5 ± 7.13
94.08 ± 16.49
103.1 ± 9.78
0.9 ± 0.11
0.6 ± 0.10
36.6 ± 4.76
30.1 ± 9.80
50.0 ± 8.65
49.8–165.0
16.3–50.3
145–204
64–145.5
87–138
0.70–1.24
0.37–0.86
28–48.5
11.4–52.9
38.9–75.0
0.188
0.141
0.826
0.475
0.068
0.564
0.433
0.860
0.278
0.680
*Independent samples t-test; comparision of food addiction Yes/No.
4
Nutritional Neuroscience
2017
Küçükerdönmez et al.
Table 3 Endorsement rates of symptoms of Yale food
addiction scale
Food addiction
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Yes
YFAS symptoms
Number
Consuming substance in
larger amount and for longer
period than intended
Persistent desire or
repeated unsuccessful
attempts to quit
Spending much time and
engaging in much activity to
obtain, use, recover
Social, occupational, or
recreational activities given
up or reduced
Continued use despite
knowledge of adverse
consequences
Tolerance (decrease in
effect, increase in amount)
Characteristic withdrawal
symptoms; substance use
to relieve withdrawal
No
%
Number
%
38
60.3
7
17.1
49
77.8
21
51.2
42
66.7
6
14.6
18
28.6
1
2.4
52
82.5
12
29.3
39
61.9
11
26.8
40
63.5
9
22.0
Table 4 The participants’ energy and nutrient intakes with
diet according to YFAS
Food addiction
Measurements
Yes (n = 63)
x ± SD
No (n = 41)
x ± SD
Energy (kcal)
2535.2 ± 887.90 1994.6 ± 700.96
Carbohydrate (gr)
322.2 ± 142.27 238.8 ± 97.71
Carbohydrate (%)
51.3 ± 7.62
48.9 ± 9.42
Fiber (gr)
28.8 ± 16.76
22.11 ± 11.71
Protein (gr)
86.0 ± 31.38
73.5 ± 36.55
Protein (%)
14.11 ± 3.79
15.1 ± 4.48
Fat (gr)
95.5 ± 30.61
79.9 ± 33.97
Fat (%)
34.6 ± 6.47
36.0 ± 8.08
Saturated fat (gr)
25.7 ± 9.71
22.1 ± 10.65
Monounsaturated (gr)
28.9 ± 10.47
25.5 ± 11.76
Polyunsaturated (gr)
34.4 ± 15.20
27.0 ± 14.23
P*
0.001
0.001
0.182
0.028
0.065
0.230
0.017
0.327
0.082
0.128
0.016
*Independent samples t-test; bold indicates significance.
The food addicts were found to have a daily energy
dietary intake from carbohydrate, proteins, and fats
of 51.3, 14.11, and 34.6%, respectively, while these
were 48.9, 15.1, and 36%, respectively, in the participants who did not have food addiction, and that no
difference was found between the groups in terms of
these values (P > 0.05).
Discussion
This study found that more than half of the schizophrenic patients (60.6%) had food addiction, and
that female schizophrenic patients had a higher prevalence (62.9%) of food addiction than male patients
(57.1%). Of the schizophrenic patients with food
addiction, 41.3% were found to be obese and their
Food addiction and nutritional status
anthropometric measurement values were higher
than those of schizophrenic patients who did not
have food addiction. Moreover, the schizophrenic
patients with food addiction were found to take
more energy, carbohydrate, and fat at significant
levels in their diet.
The majority of the schizophrenic patients (60.6%)
were found to have food addiction. Studies found
that the prevalence of food addiction varies considerably according to the chosen sample.14,31 A study by
Berenson et al.32 found that the prevalence of food
addiction was 2.8% among healthy women, while
other studies conducted by Yu et al.33 and Pursey
et al.34 found it as high as 10.3, and 22.3%, respectively. Studies also found that the prevalence of food
addiction varied between 16.5 and 32% among
patients undergoing bariatric surgery.35,36 Studies conducted with major depressive patients reported that
56.8% of them had food addiction.37 The highest percentage of food addiction was found among bulimic
patients, where it varied between 83.6 and
100%.11,15,38
Meule et al.39 reported that food addiction is
observed more often among obese individuals, while
Hauck et al.16 found the prevalence of food addiction
to be 7.9% in the general German population and
17.2% among obese individuals. A study by Meule,
de Zwaan, and Müller40 with obese individuals
found that the prevalence of food addiction was
47.4%. Another study conducted in the general population found that 5.4% of individuals had food addiction and their body weight, BMI, and body fat were
11.7 kg, 4.6 kg/m2, and 8.2% higher, respectively,
compared to those who did not have food addiction.41
A meta-analysis conducted by Pursey et al.14 found
that the prevalence of food addiction was 19.9% and
this was 24.9% among obese individuals. This study
found that the rate of obesity among schizophrenic
patients with food addiction was approximately
twice as high as in those who did not have food addiction. The BMI was found to be higher than 25 kg/m2
in 74.6% of the food addicts and 61% of those who did
not have food addiction. Previous studies showed that
the rate of obesity among schizophrenic patients was
two or three times higher than in the general population.5,42 Another study found that the rate of slightly
overweight and obese individuals among schizophrenic patients varied between 48 and 79%.43,44
It is known there are similar pathways in food addiction and substance addiction. A study found that when
images of appetizing foods (foods containing fat and
sugar at high levels) were shown to study participants,
the reward area in their brains which is related to substance addiction became activated and dopamine was
released automatically.45 The brain-reward system
consists of the mesolimbic dopamine system (the
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2017
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Küçükerdönmez et al.
Food addiction and nutritional status
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ventral tegmental area, nucleus accumbens (NAc),
prefrontal cortex, amygdala), lateral hippocampus,
and medial forebrain. This system shows its effects
mainly via dopamine. The dopaminergic system is in
a continuous communication with opioid-mediatedgabaergic system, cholinergic system, and serotoninergic system. These systems can modulate the activation
of the reward system and the release of dopamine.46,47
A study by Leigh and Morris48 showed that when a
highly tasty diet is eaten, the expression of D1 dopamine receptor mRNA levels decreases, the striatal
D2 dopamine receptor levels may be associated with
obesity predisposition, and mu-opioid gene expression
decreases in NAc.
It is thought that the dysfunction observed in the
brain-reward system may be the common ground for
substance addiction, schizophrenia, and food addiction. A study by Grimm et al.49 reported that the
core of psychopathology in schizophrenia is formed
by the dysfunction in the striatal dopamine system
and the problems in this system lead to an increase
in the prevalence of obesity among individuals with
mental disease, causing changes in the reward
systems of individuals and their body weight. Other
studies showed that the system related to the reward
process of the brain, which is innervated by dopamine
via the mesolimbic and mesocortical pathways, is corrupted in schizophrenic patients.18,50 A neuroimaging
study conducted by Zhou et al.51 found that important
structural changes take place in many parts of the
brain, including the limbic system, which includes its
reward system, in schizophrenic patients.
Antipsychotic medications are the keystone for
schizophrenia treatment and constitute a major
factor affecting the brain’s reward system.
Antipsychotic medications show their effects as dopamine receptor (D2) antagonist that decreases the dopamine levels in the ventral striatum, which is the center
of the reward system and disorders in the brain’s
reward system. Since typical antipsychotics have a
more potent D2 receptor antagonism than atypical
antipsychotics, they are associated with more negative
effects in the brain’s reward system. This hypodopaminergic state is characterized by the emergence of anhedonia, apathy, and other negative symptoms in
schizophrenic patients and is called neuroleptic dysphoria.52,53 A reward deficiency hypothesis was
suggested for this hypodopaminergic state, which is
also caused by the antipsychotic medications.
According to this hypothesis, the decrease in dopamine activity causes individuals to compensate for
this deficiency through overeating resulting in abnormal craving behaviour, englutting, and obesity.54,55
Haloperidol and risperidone are antipsychotics with
the highest D2 receptor affinity, and they are powerful
D2 receptor antagonists. Quetiapine and olanzapine
6
Nutritional Neuroscience
2017
have a low affinity towards the D2 receptor, thus,
leading to lower levels of D2 receptor antagonism.56
This study found that the use of haloperidol, a
typical antipsychotic, caused the highest rate of food
addiction. All of the participants using haloperidol
were found to have food addiction. Among the individuals using atypical antipsychotics, the highest percentage of food addiction was found in those using
risperidone (83.3%) while the lowest percentage was
found in those using olanzapine (53.3%). These
results were in accordance with previously reported
studies. The use of monetary incentive delay task in
schizophrenic patients using antipsychotics such as
olanzapine and risperidone showed ventral striatum
activation. However, this activation was not found in
patients using haloperidol, and a correlation was
found between the decrease in ventral striatum activation observed as a result of the use of haloperidol
and the severity of negative symptoms.57 Notably,
these results showed that patients using olanzapine,
which is a medication causing maximum weight
gain, had the lowest level of food addiction. A
similar situation was observed in those who were
using quetiapine, which causes moderate weight gain
suggesting that antipsychotic medications have multifactorial effects. These medications also show antagonistic effects on the serotonin receptor subtypes 5HT2A, 5-HT2C ve 5-HT6, histamine H1 receptor,
muscarinic M3 receptor, and adrenergic receptors at
different levels, in addition to the dopamine receptors.
A study showed that the blockage of these receptors
exerts a synergistic effect on the increase in the appetite
and food intake of schizophrenic patients and causes a
substantial weight gain in these individuals. Although
the rewarding system, which is modulated by the
impaired dopaminergic activity in the patients with
schizophrenia, may be improved with antipsychotic
medications, the negative effects of these medications
on the opioidergic activity caused weight gain
because they increased insulin resistance and appetite.58–60
Anthropometric parameters such as BMI, waist circumference, waist-to-hip ratio, and waist-to-height
ratio are methods commonly used for the assessment
and rating of general and central obesity and whose
application and interpretation are very practical.
Studies reported that the increases in the values of
these parameters cause increased risk for diabetes, dyslipidemia, hypertension, other cardiovascular diseases,
and metabolic syndrome.27,61 Studies conducted in
schizophrenic patients showed that the rate of obesity
among these individuals is two or three times higher
than the general population.4,62 Moreover, studies
found that compared to the general population, the
risk of obesity-related diabetes is two or five times
higher, the risk of metabolic syndrome is three to
Downloaded by [Chalmers University of Technology] at 00:45 29 October 2017
Küçükerdönmez et al.
four times higher, and the risk of death from cardiovascular diseases is two to three times higher in schizophrenic
patients.63–66
The
anthropometric
measurements performed for the schizophrenic
patients in this study showed that the number of
slightly overweight and obese patients was high.
Moreover, the body weight, BMI, waist circumference,
and body-fat percentage values of schizophrenic
patients with food addiction were found to be higher
than those of schizophrenic patients who did not
have food addiction (P > 0.05). According to these
results, it can be stated that the risk of contracting
obesity-related diseases is higher among schizophrenic
patients with food addiction.
This study found that the YFAS symptom score of
schizophrenic patients having food addiction was 4.5
± 1.20. This study also found that the symptom most
commonly observed in the individuals with food
addiction was ‘continued use despite knowledge of
adverse consequences’ (82.5%), which was followed
by ‘persistent desire or repeated unsuccessful attempts
to quit’ (77.8%). A meta-analysis conducted by Pursey
et al.14 reported a YFAS symptom mean score of 4.0 ±
0.5, and the symptom most commonly observed in
individuals with food addiction was ‘persistent desire
or repeated unsuccessful attempts to quit.’ This result
was in accord with the studies conducted in obese individuals wanting to lose weight, in the general population, in obese individuals and bulimics.30–32,67,68
The other symptom most commonly observed in
these studies was found to be ‘continued use despite
knowledge of adverse consequences.’ Berridge argues
that when examining the role of food reward in
eating behaviour one has to differentiate between
food liking and food wanting, with ‘liking’ roughly
referring to palatability (i.e. the pleasure derived
from eating a given food) and ‘wanting’ referring to
appetite (i.e. the disposition to eat). Within animal
research, food wanting is typically measured as instrumental behaviour to obtain food reinforcement;
whereas food liking is assessed by observing facial
taste reactivity patterns.69 It suggests that dopamine
mediates the ‘wanting’ but not the ‘liking’ component
of rewards.70 Thus, deficits in dopamine function
might lead to a disturbance in incentive drives or
approach behaviour that would lead to the obtainment
of a rewarding stimulus, even if the hedonic response
to that stimulus is intact.71 This study found that the
least common symptom was ‘social, occupational, or
recreational activities given up or reduced.’ This
could be mainly because schizophrenia disrupts the
intrapersonal and interpersonal functions of individuals and consequently causes the quality of social life
to decrease.72
McCreadie25 reported that schizophrenic patients
lead a sedentary life, their cigarette consumption is
Food addiction and nutritional status
high, and they have bad eating habits. A review
study conducted by Dipasquale et al.3 found that the
fruit and vegetable intakes of schizophrenic patients
are at very low levels, while they consume a large
quantities of food products containing saturated fat
and refined sugar. This study found that the schizophrenic patients with food addiction were taking
more energy, carbohydrate, and fat at a significant
level in their diet, compared to those who did not
have food addiction. The diet pattern of schizophrenic
patients who did not have food addiction was found to
show similarity with previous studies.73,74 The energy
from fat in the daily diets of individuals in both
groups was found to be higher than the reference
values. It is known that increased fat intake is associated with cardiovascular diseases. Moreover, studies
reported that an increase in fat intake causes psychiatric symptoms to increase in these patients. A study
found that the course of schizophrenia in the regions
where the saturated fat intake was high, was worse
than that in regions where vegetable oil and marine
products are consumed.75 Another study found that
an increase in sugar consumption is associated with
serious negative effects on the course of schizophrenia
in the long term.76 Given that food addicts consume
foods containing high levels of fat and sugar, these
foods may cause psychiatric symptoms to become
more severe, as well as causing obesity and cardiovascular diseases.
Conclusion
Health problems such as obesity, diabetes, dyslipidemia, and metabolic syndrome are common in schizophrenic patients because of low levels of physical
activity, poor eating habits, some side effects of antipsychotic medications, and problems they have in
accessing health care services. The higher rate of
obesity in schizophrenic patients with food addiction
may cause an increase in the prevalence of these
health problems. Therefore, healthy nutrition education programs should be developed for schizophrenic patients, studies should be conducted to
increase their physical activity levels, and efforts
should be made to improve the quality of life of
these patients. Further studies should be conducted
to better understand the underlying mechanisms of
the relationship between schizophrenia and food
addiction.
Disclaimer statements
Contributors None.
Funding None.
Conflicts of interest None.
Ethics approval None.
Nutritional Neuroscience
2017
7
Küçükerdönmez et al.
Food addiction and nutritional status
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