How Relevant is Food Craving to Obesity and Its Treatment?

Cravings represent strong motivational states that are characterized by intense desires typically relating to the anticipation of consuming pleasure-producing substances or engaging in hedonic behaviors. In considering food craving and the extent of its applicability to food, a brief review of the history of craving within a culture-sensitive framework appears warranted. Many cultures appear to have considered cravings in different contexts over time, although it has been contended, based on analyses of translations and lexicalization across languages, that craving may fail to translate outside of Europe and North America, although there are similarities in the use of craving and addiction across domains of use (1). The word “crave” is derived from the Old English crafian meaning to beg1. Over time, the term craving became linked to excessive patterns of substance use. For example, in the early nineteenth century, in conceptualizing excessive patterns of alcohol consumption, the term dipsomania (translated from the German term Trunksucht, or drinking addiction) was described to define alcoholism as a condition characterized by a craving for continued intoxication (2). In Buddhism, the term tan.hā is commonly translated to mean craving (although its literal translation is “thirst”), with kāmatan.hā (sense-craving) describing strong motivations to experience pleasant feelings or sensory pleasures2. In Buddhism, tan.hā is seen as a type of ignorant desire and a cause of suffering and negative affective states, and some current approaches to understanding treatment mechanisms and promoting treatment development in addictions have involved considering craving within a Buddhist context (3, 4). Thus, links between cravings and negative processes including addictions have a longstanding history across multiple cultures. In current psychiatric conceptualizations of addictions, cravings are considered an important component. Although substance-use disorders have been included in prior editions of the Diagnostic and Statistical Manual, a change from DSM-IV to DSM-5 involved the addition of an inclusionary criterion targeting craving in the diagnosing of substanceuse disorders (5, 6). Despite the only recent addition of craving to the formal diagnostic criteria for substance-use disorders, craving has long been considered an important and clinically relevant feature of substance-use disorders. Craving has, for example, been linked in important fashions to treatment outcomes for both pharmacological interventions [e.g., naltrexone in the treatment of alcohol dependence (7)] and behavioral therapies [e.g., cognitivebehavioral therapies (8)] for substance addictions. Findings linking craving and treatment outcomes also appear applicable to non-substance or behavioral addictions; for example, in individuals with pathological gambling receiving opioid-receptor antagonists (naltrexone or nalmefene), individuals with strong gambling urges or cravings at treatment onset were more likely to demonstrate a better treatment outcome (9). Despite the apparently widely appreciated relevance of craving to substance-use disorders and their treatment, the relevance of addiction features, including craving, to eating behaviors and conditions relating to excessive eating [e.g., obesity or bingeeating disorder (BED)] is more controversial and a topic of considerable debate (10– 13). Some investigators have posited that energy balance remains central to obesity and that addiction or related aspects may represent a relatively minor component (13). Other investigators have suggested that a rapidly changing food environment may be contributing to the increases in obesity that have been observed over the past 30–40 years (14). Specifically, given the relative abundance and availability of inexpensive foods, it is possible that motivations to consume highly palatable foods, and perhaps large portions thereof, have taken a larger role in contributing to eating behaviors than in years past when the motivation to eat may have been more closely linked to energy restoration (15). Thus, examining other addiction-related constructs, such as food craving, as they relate to obesity and other food-related conditions seems relevant. Multiple and diverse studies suggest that food cravings may be clinically relevant to understanding aspects of obesity and associated forms of disordered eating such as BED. Naturalistically and clinically, many individuals with overeating concerns and with BED report seeking