Food addiction (FA) is an increasingly relevant clinical and public health issue given its impact on metabolic health, mental health, and quality of life. Therapeutic carbohydrate reduction (TCR) has been shown to improve the symptoms of food addiction as measured by the modified Yale Food Addiction Scale (mYFAS) 2.0. We discuss a novel telemedicine intervention, in an employee wellness setting, utilizing TOWARD principles: Text-based communications, Online interactions, Wellness coaching, Asynchronous education and community support, Real-time biofeedback and remote monitoring, and Dietary modification with an emphasis on TCR to treat symptoms of food addiction and binge eating.
Understanding Food Addiction and Binge Eating
Food addiction (FA) describes a collection of symptoms that closely mirror those observed in substance use disorders (SUD). FA is characterized by physical and psychological dependence on foods that are typically highly processed with large quantities of sugar and processed oils (1). While not formally recognized as a diagnosis in the DSM-V or ICD-10, growing research and clinical attention have focused on FA as a potential contributor to emotional distress and chronic metabolic diseases (2). The Yale Food Addiction Scale (YFAS) and its updated versions have been instrumental in characterizing addictive-like eating behaviors. The original YFAS was constructed and validated in 2009 and consisted of 25 items paralleling the DSM-IV criteria for SUD (3). This instrument has been validated across diverse populations, including non-clinical groups, individuals with obesity, and those with eating disorders. In 2017, YFAS Version 2.0 (YFAS 2.0) and mYFAS 2.0 were introduced to align with the DSM-V criteria (4).
Conversely, binge eating disorder (BED) is a formal diagnosis in the DSM-V and ICD-10. Binge eating symptoms are characterized by recurrent episodes of consuming excessive amounts of food in a short period, often accompanied by a loss of control, feelings of distress, and an absence of compensatory behaviors like purging. Validated tools like the Binge Eating Scale (BES) and Binge Eating Disorder Screener 7 (BED-7) have been used to assist in determining the severity of the symptoms and aiding in diagnosis (5).
Significant overlap exists between FA and BED as evidenced in a 2023 comparative review with symptoms including increased impulsivity, mood changes following food consumption, and overindulgence with difficulty controlling urges/cravings (6). There are some important differences between these two entities. FA is characterized by tolerance, withdrawal, and intense cravings for specific hyperpalatable foods, whereas BED is defined by episodic loss of control over the quantity of food consumed, often without a consistent craving for a particular type of food.
These clinical entities are of increasing interest among patients and providers as they complicate the care of chronic diseases including obesity, diabetes, and mood disorders while also negatively impacting quality of life (7, 8). A 2022 systematic review and meta-analysis reported an overall FA prevalence of 20%, with rates as high as 55% among individuals with BED, 28% among those with obesity, and 30% among those with type 2 diabetes (11, 12). FA impacts nearly 70 million U.S adults (13) and is a noteworthy barrier to lifestyle change and positive health outcomes (14-16). In this context, therapeutic carbohydrate reduction (TCR) using low-carbohydrate diets (LCDs) has emerged as a promising intervention. LCDs including ketogenic diets have been extensively studied in an array of patient populations including metabolic syndrome, hypertension, type 2 diabetes, migraines, Parkinson’s, epilepsy, cancer, and recently in mental health conditions (17-33). Successful application of this strategy depends on sustained behavior change. Virtual programs that combine frequent contact with education and coaching have been effective for metabolic health and may offer similar benefits in addressing food addiction (19, 22, 24). Early evidence suggests similarly intensive telemedicine programs can help with addictive eating behaviors. A 2022 cohort study conducted across the UK, North America, and Sweden demonstrated promising results through combining TCR and coaching which led to meaningful decreases in FA symptom scores using the modified Yale Food Addiction Scale 2.0 (mYFAS 2.0) (34). This tracks with evidence in the SUD literature that shows intensive support groups help those with SUDs, like alcoholics anonymous for those with alcohol use disorder and 12 step facilitation (35).
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Treatment of metabolic disease can be challenging and often requires a multimodal approach. While pharmacotherapy and behavioral therapies are commonly cited methods for managing these conditions, TCR and intermittent fasting (IF) is an important treatment modality for consideration, particularly in the context of FA and BED (36). Additionally, pharmacologic strategies are often limited by side effects, long-term adherence, failure to address the root cause, and incomplete symptom relief, creating the need for adjunctive or alternative interventions.
The TOWARD Program: A Novel Telemedicine Intervention
The primary objective of this paper is to evaluate changes in food addiction and binge eating symptoms following participation in a real-world, multimodal, metabolic health intervention incorporating TCR, IF, and remote monitoring. While the program tracked a variety of biometric, metabolic, and mental health variables, this manuscript focuses specifically on outcomes related to compulsive eating behaviors (YFAS and BES). Results related to weight, lab values, and medication deprescription were previously published (22).
Program Implementation
A self-insured manufacturing company partnered with a metabolic health clinic to implement an employee metabolic wellness program in October 2021. The primary goal of the program was to holistically improve employee health, with an emphasis on weight loss and metabolic disease management as the main communication points to employees. As this is a real-world, ongoing wellness program, periodic reassessment by the clinical team has informed quality improvement initiatives and led to adaptations over time. Notably, the generalized anxiety disorder 7 (GAD-7) was added as an additional psychometric tool, and the frequency of questionnaire administration increased from every two years to every six months. This led to variability in response rates and non-standardized time points for post-intervention data collection.
Key Components of the TOWARD Program
The TOWARD program utilizes several key components to address food addiction and binge eating:
- Text-Based Communications & Messaging: Patients used a HIPAA-compliant text messaging system to interact with their health care team, ask questions, and receive behavioral coaching and motivational messages.
- Online Interactions with Clinical Teams: Participants engaged in virtual telemedicine visits with a multidisciplinary team, including physicians, physician assistants, medical assistants, personal trainers, and health coaches. These sessions provided medical oversight, individualized treatment plans, and adjustments to metabolic interventions. Visits included a combination of one-on-one sessions with patients and either their health coach or provider, as well as an initial joint visit with both the health coach and provider.
- Asynchronous Education & Community Support: Participants accessed an educational platform that included self-guided learning modules on the science of hunger, appetite regulation, food addiction, and emotional eating.
- Real-Time Biofeedback & Remote Monitoring: Participants were provided with continuous glucose monitors (CGMs), glucose-ketone meters, body weight scales, and blood pressure monitors.
- Dietary Modifications: The program emphasized Therapeutic Carbohydrate Reduction (TCR), reducing total carbohydrates to fewer than 30g daily without counting non-starchy vegetables and leafy greens. Patients were told to focus on using avocado oil, butter, olive oil, or ghee for cooking and avoid highly processed oils and fats.
Individualized Intervention
Health coaches used self-reported feedback and biometric data to tailor the intervention based on individual patient needs, addressing issues such as increased cravings, feelings of deprivation, and emotional stressors impacting eating behaviors. As the intervention progressed, the clinical team began tracking YFAS, BES, GAD-7, and PHQ-9 scores longitudinally to monitor patient progress and ensure improvements were occurring. However, because these were not initially required components of the structured intervention, not all participants completed follow-up assessments, leading to variability in response rates and non-standardized timeframes for post-intervention data collection.
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Data Analysis
To enable pooled analysis, scores from both the YFAS and mYFAS 2.0 were analyzed as change from baseline instead of absolute change. Descriptive statistics were used to summarize baseline and follow-up data, including means, standard deviations, and 95% confidence intervals. All analyses were conducted in R version 4.4.1.
Results of the TOWARD Program
Results are reported on 44 patients. 37 individuals completed two YFAS questionnaires and 37 individuals completed two BES questionnaires. 100% of individuals had a metabolic health condition and 22.7% of individuals had a baseline mental health condition. 45.9% (17 out of 37) of patients demonstrated improvement in YFAS scores, with the average decreasing from 2.58 to 1.53, a 40.7% drop from baseline. 18.9% (seven out of 37) individuals started with a score of 0 and ended with a score of 0. 81.1% (30 out of 37) of patients demonstrated an improvement in binge eating scores, with the average decreasing from 17.3 down to 11.3, a 34.7% drop from baseline. Food addiction symptoms decreased by 40.7% and binge eating symptoms decreased by 34.7%.
Discussion
The public health sector continues to be plagued by many chronic diseases often marked by poor metabolic and mental health. FA, particularly to ultra-processed foods, can be a significant driver of maladaptive behaviors toward progressively worsening symptoms (37). Unwin et al. (2022) utilized a whole food, low-carbohydrate diet in conjunction with intensive educational intervention using a FA recovery model (34). This ultimately led to significant reductions in patients’ FA symptoms and improved mental wellbeing (34). A case series involving three patients with obesity, binge eating, and food addiction showed remarkable improvements following a ketogenic diet (36). The current TOWARD study cohort was involved in an intensive clinical intervention using TCR, alongside remote monitoring, a smart phone application, and behavioral support, to improve FA and binge eating symptoms.
Recently, there has been an increased awareness of FA and the need for effective interventions. Both lifestyle modifications and medications have been studied. Lifestyle modification interventions involving intensive caloric restriction with meal replacements and gradual reintroduction of conventional foods has demonstrated clinically insignificant effects on FA symptoms (39). For example, in one study of 138 individuals, participants underwent a structured lifestyle intervention consisting of 14 weekly sessions of group counseling, caloric restriction (1000-1200 kcal/day) from a meal replacement program, and progressive physical activity up to 175 minutes per week (39). Original YFAS scores decreased from 2.24 at baseline to 1.93 post-treatment, only 13.8%. Comparatively, the TOWARD intervention showed weight-loss-independent reductions in FA symptoms by 40.7% (YFAS change of -1.12, SE: 0.39, p=0.007). Additionally, the TOWARD program did not rely on caloric restriction or meal replacements, instead emphasizing long-term dietary changes through TCR and behavioral support. In combination with the data from Unwin et al.
Another population that has been found to have higher rates of FA is individuals undergoing bariatric surgery (40). There have been several studies showing that bariatric surgery improves FA symptoms (41, 42). Murray et al. (43) found that 16 individuals who underwent Roux-en-Y gastric bypass or sleeve gastrectomy had significant reductions in YFAS scores of approximately 1.9 to 0.9 between baseline and 4-month follow-up, whereas those receiving dietary interventions consisting of liquid meal replacements for 3 months or no treatment showed no significant changes. A larger study of 178 patients undergoing bariatric surgery found even more significant reductions in YFAS scores from 3.76 down to 2.06 at 1-year follow-up (45.2%) (41). Interestingly, there was no correlation between the reduction in food addiction symptoms and the magnitude of weight loss, a finding also observed in the TOWARD intervention.
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Pharmacological treatments have been explored for the management of binge eating symptoms as well as FA, such as lisdexamfetamine (LDX), semaglutide (SEMA), topiramate (TPM), and other anti-obesity medications (OAOMs). Unfortunately, they come with adverse effects and are often discontinued due to these adverse effects (42, 44). Currently, LDX is the only FDA approved medication for binge eating disorder. In two studies, LDX alone significantly improved binge eating symptoms, and a combination of LDX plus TPM was also effective (42, 45). These results indicate both medications can be effective, however, their benefits must be weighed against the risks of adverse reactions and high discontinuation rates. 81.3% and 84.4% of individuals on LDX and LDX plus TPM had dry mouth, 56.3% and 20% had insomnia, 25% and 15.9% had anxiety, 18.8% and 5.7% had irritability, 25% and 11.1% had headache, and 0% and 22.2% had paresthesias, respectively (42). Other side effects with a greater than 10% occurrence rate included palpitations, bruxism, nausea, emotional liability, fatigue, ataxia, dizziness, and increase in systolic blood pressure >10 (42). In contrast, most individuals in the TOWARD program did not suffer from major side effects.
SEMA and OAOM have also shown effectiveness in improving the BES. Richards et al. found that BES decreased most substantially with a combination of SEMA and OAOM, nearly as effective with SEMA alone, and about half as effective with OAOM alone (BES reductions 8.8, 7.9, and 4.8, respectively) (46). These findings from SEMA and OAOM are similar to our cohort that showed an improvement in BES by 6.0 points. Other pharmaceuticals have also been studied for BED. In a randomized, placebo-controlled crossover trial, phentermine-topiramate extended release was found to significantly decrease the number of binge eating days over four weeks from 16.2 days to 4.2 days, compared to 13.2 days with placebo (48). Research is ongoing to explore pharmacotherapy for FA with and without binge eating. Carbone et al. (2021) found that those with binge eating disorder (BED) and FA symptoms had more severe food addiction symp…