The current medical and dietetics paradigm don't agree with each other on the concept of food addiction. Some scientists argue that we can get rats to choose sugar over cocaine, thus proving its addictive qualities. Meanwhile, other scientists argue that a person cannot be addicted to something they need to survive, and we need food to survive.
But while scientists fight, our patients are suffering. Many of my patients have come to me saying "I feel addicted to chocolate". Or they have said "I have eaten pizza until it hurts," They may have a tendency to hide wrappers, to sneak food, to wait and not eat all day, only to lose control when they get home. Maybe they do great all day with their lifestyle, but the minute the kids are asleep it's as if they cannot control themselves. This problem is particularly bad late at night. Some of my patients avoid eating in front of others, but then binge at home.
How can physicians and patients determine if there is an issue with a patient's relationship to food?
I didn’t realize I was battling addiction myself until I gave a CAGE questionnaire to one of my patients to determine if they were struggling with alcohol abuse. My personal addiction wasn’t alcohol. As a 350lb physician who desperately wanted to lose weight but couldn’t, my addiction was food. As I went through the questions, “Have you ever felt the need to cut down on your substance use? Have people annoyed you by criticizing it? Do you feel guilty about it? Have you ever used a substance first thing in the morning as an eye-opener?” I started to see myself in every one of them. By the time I finished, I realized I was four for four. The acronym stands for Cut, Annoyed, Guilty, and Eye-opener, and I fit every category. That was the moment it hit me. My addiction was food.
Our modern food environment feels like a casino. It’s designed to keep us hooked. People have lost their sense of how to eat, and even doctors, dietitians, and trainers are often confused. This confusion feeds into a system where there are clear winners and losers. The winners? Processed food companies, pharmaceutical giants, and the healthcare industry. The losers? People like me and the patients I see every day. I saw my family lose from a young age, watching obesity, diabetes, and heart disease ravage them. I got tired of watching people lose. I saw myself losing. That frustration is what drives me forward.
At my practice, I focus on providing real, meaningful support to help patients break free from the traps of modern eating. We have a wellness coach who works closely with patients to uncover their eating patterns and pinpoint their vulnerabilities. Education is at the core of what we do. We teach patients not just about hunger and appetite, but also about food addiction and how it impacts their lives. We’ve also embraced technology to keep a close eye on our patients’ health. With tools like continuous glucose monitors, smart scales, and blood pressure cuffs linked directly to our office, we can track their progress in real-time and make adjustments as they go.
I’ve come full circle with the CAGE questionnaire, now using it to understand where my patients fall on the spectrum of food dependency. The acronym stands for Cut, Annoyed, Guilty, and Eye-opener, and it was originally designed to assess alcohol addiction. I’ve adapted it to food addiction by asking similar questions: “Have you ever felt the need to cut down on certain foods? Do you get annoyed when people comment on your eating habits? Do you feel guilty about your relationship with food? Do you ever feel like you are eating large amounts of ‘junk food’ at odd hours, late at night? Do you find yourself hiding or sneaking food? Or maybe eating well all day in front of others, then eating too much alone or in private?”
Each question reveals something critical. If a patient says they want to cut down, it tells me they recognize the harm and want to change. However, that alone doesn’t mean they’re addicted.
It’s this next question that begins to reveal the story: “Do you get annoyed when people comment on your eating habits?” This is where emotions come into play. That annoyance isn’t just frustration. It’s a sign of a deeper emotional conflict, one that separates the person’s actions from their goals.
When I was 350 lbs. and desperately wanted to lose weight, I would get angry when people suggested I eat less or something different. I chalked it up to being stubborn or not wanting to be told what to do. That was a lie. The food was manipulating my emotions, making me angry and resistant. So when patients tell me they get angry too, it reveals something deeper—a huge emotional disconnect. They should feel delighted that someone cares enough to help them on their health journey, but they don’t. This emotional disconnection is critical to understand because food addiction twists their emotions, preventing them from aligning with their goals.
And then there’s guilt. This one hits hardest. When a person feels extensive shame and guilt, it typically means their underlying emotional disconnect from their goals is so strong, and their captivity by the substance so pervasive, that even their desire to change isn’t enough to overcome it. This creates profound psychological and even spiritual distress. They feel trapped, unable to break free from behaviors that go against their deepest intentions. This is why so many report intense feelings of guilt and shame. It’s not just about overeating. It’s about the crushing weight of being out of alignment with their own goals, stuck in a cycle of frustration and despair.
Then there’s the "eye-opener" question. For food, this isn’t about steadying your nerves like it might be with alcohol. It’s about compulsive behaviors like late-night binges or sneaking food when no one is watching. It’s about hiding what you’re eating because you know it’s too much or the wrong thing.
When the emotional and psychological disconnects are so strong, the person begins to modify their behavior to accommodate the substance. They eat in secret to avoid psychological distress. They sneak or hide food for the same reasons. Instead of eliminating the substance, which is their ultimate goal, they adjust their behavior to allow its continued use. Over time, their psyche finds ways to justify or minimize the shame and guilt, leading to larger and larger quantities of the substance. The food has literally taken over. This is full-blown addiction.
My personal struggle with food addiction and the realization of how deeply it had taken over my life became a turning point. It wasn’t just for me, but for how I practice medicine. The lessons I’ve learned from my own experience, combined with the use of tools like the adapted CAGE questionnaire, have transformed how I approach food addiction in my patients. This simple yet powerful framework has helped me uncover the emotional disconnects and behaviors that keep people trapped in a cycle of addiction, shame, and disease.
But my journey isn’t just about me. The tragedy of my own struggle, along with my clinical experience, offers a roadmap for others. Doctors, dietitians, and healthcare professionals—and yes, even your friends and family members—can better recognize food addiction and address it head-on. By understanding the emotional and psychological barriers that drive these behaviors, we can provide the tools and support patients need to break free.
Food addiction isn’t just a personal battle. It’s at the heart of the chronic disease epidemic we face today. If we, as healthcare professionals, can use tools like CAGE to identify food dependency and address it with compassion and evidence-based strategies, we have the potential to reverse this epidemic and restore health and dignity to countless lives. The fight against food addiction isn’t just critical. It’s urgent. Together, we can make a difference.
There are other very long and validated surveys, some of which my patients receive: The Yale Food Addiction Scale and the Binge Eating Scale, are two commonly accepted means of assessing a patient's relationship to food. However, they are cumbersome and largely for research purposes only.
Summary:
Although the CAGE questionnaire has not been officially validated for binge-eating and food addiction, the CAGE questionnaire is a validated measurement tool for alcohol dependence. In our practice, we have modified CAGE as a quick screen for binge-eating and food addiction.
What is the CAGE questionnaire?
C – Have you ever felt you should cut down on your consumption?
A – Have people annoyed you by criticizing your consumption?
G – Have you felt bad or guilty about your consumption?
E – Have you ever had a snack to steady your mood? (Adopted to food: Do you sneak your consumption? Do you lose control? Do you have intense shame/guilt and psychological distress related to your consumption?)
If a person answers 1-2 positive, we generally aren't too concerned about their relationship to food; we know that we can focus on the nutritional aspects of lifestyle. If a patient scores 3-4, we may consider some more standardized testing but our practice will be more likely to focus the lifestyle program on the behavior and relationship to food and not solely nutrition or weight loss.
If you score a 3 or 4 out of 4, please consider watching the below lecture in its entirety.
You are not alone.
