It is hard to believe that it has been one year since the first COVID-19 lockdowns occurred in the US and Canada. Over the past year, many people’s daily routines have completely changed as they physically and socially-distance from others. While this distancing has been crucial to reduce COVID-19-related deaths, a question that scientists and practitioners have been facing is “Have there been harmful effects on alcohol use and related deaths?” Let’s look at the data together and see what’s the matter.
The Quarantini
Over the past year, many bars and restaurants have had to limit “drink-in” services. At the same time, many rules around alcohol sales and delivery have laxed (cocktail delivery – anyone?) and alcohol vendors have been deemed essential services.
It is not possible to know for sure if the pandemic has changed drinking. This is would require a study where we control people’s exposure to pandemic-like conditions and give them alcohol to see what happens (aka an experiment). What we do know, however, is that in some regions during certain periods of the pandemic there have been increases in the sale of alcohol. Of course, based on this alone, we do not know if people are drinking that extra alcohol they have purchased or if it is now part of a new pandemic trend of building a wine cellar.
We also know that people are telling us they are drinking more. In an online survey of 320 Canadian adults who drink, some individuals reported increased alcohol use when the pandemic started [1]. Some people reported greater increases in drinking than others, such as individuals who had children under the age of 18, had greater depression, or were less socially connected to others. An important question is why are certain people drinking more during the pandemic?
Tears in Your Beer
While alcohol use is often thought of as a social activity, how has social distancing and the pandemic affected people’s alcohol use?
The COVID-19 pandemic is a stressful ongoing event affecting the lives for many people. For quite some time, researchers have argued that feeling stressed, sad, or anxious can lead individuals to use substances (like alcohol) to cope with those unwanted feelings. Consistent with this idea, research supports that individuals who were more likely to report drinking alcohol to deal with negative emotions during the pandemic were most likely to increase their alcohol use.[1] Drinking to cope with negative emotions also was associated with experiencing consequences from drinking, such as being unhappy, getting in trouble, doing impulsive things, and harming relationships.
A Short-Term Solution that can create Longer-Term Problems
Attention has been drawn to recent increases in “deaths of despair” that include deaths from alcohol and other drug overdoses (as well as liver disease and suicide).[2] For instance, in Ontario, there was an increase in opioid-related deaths after the state of emergency was declared in March 2020 (see page 5 ). While there are many possible explanations for this increase, one possibility that has been put forward is that the sudden and then ongoing stress of the COVID-19 pandemic has led individuals to drink to cope and this can fuel an increase in drinking and potentially harms from drinking (such as overdose and alcohol-related liver disease).
As the COVID-19 pandemic continues to burden us with considerable stress and worry, alcohol serves as only short-term solution to a longer-term problem. As stated by Koob and colleagues (2020):
“Alcohol can temporarily dampen negative emotional states, providing short-term relief…Over time, [changes to the brain] reduce the relief that is provided by alcohol and increase emotional misery between episodes of [alcohol] use.”
In other words, alcohol may help relieve distress in the short-term, but in the longer term, it can make distress much worse.
Given the potential physical, emotional, and financial costs of drinking, alternative ways of coping with COVID-19 related distress are needed. It is important to find options that will work for you and your current pandemic lifestyle. It may not be easy, but your mind and body may thank you later for finding alternative ways to relax and take a break.
Here are some options that you could try!
Enjoy a different beverage: your favorite soda, a warm tea, or an indulgent hot chocolate
Find another way to temporarily escape: have a bubble bath, listen to your favourite album, or watch a new show
Develop new ways of coping: practice mindfulness, start a new exercise routine, go for a walk
Reconnect with others: plan a virtual game night or simply catch-up with others by phone
Where can I find out more about reducing my drinking?
Khantho (2016). Photograph of a person holding an ice cream cone.
Every day you pick up a delicious ice cream cone on your way home from work. But this time you decide it might be better to skip a few days, maybe for health reasons or to save some money. It’s been a couple of days when you pass by the ice cream shop and notice that this treathas been on your mind all day, making it hard to concentrate at work. You notice a strong craving for one and you’re finding yourself feeling irritable without one. You think, “What’s going on? Do I have a problem?”.
At this point, you might wonder if you’re experiencing withdrawal symptoms by cutting back on this ice cream, like what might happen when someone who has substance or drug issues cuts back on their use. For example, when someone who often drinks a lot of alcohol cuts back on their drinking, they may feel uncomfortable or ill. They may experience anxiety, nausea, and sweating [1]. These symptoms that happen when substance use is reduced is called withdrawal. Even though withdrawal is well-known for substances, it is not well understood for food, despite food being necessary for survival and being readily available for many people, often in large quantities.
But why is this important? Some theories of why people develop substance problems (described more below) focus specifically on withdrawal symptoms. For these theories to apply though, understanding if withdrawal even exists for foods is important to know. This blog post reviews the current scientific evidence to answer the question: Can we experience withdrawal symptoms when we cut back on certain foods?
What is food addiction and how does withdrawal fit in?
Withdrawal is one symptom of many that people can experience when they have a substance use disorder, or more commonly known as an “addiction” [1]. The idea that food can also be addictive has attracted more scientific attention in the last decade and since the publication of a questionnaire called the Yale Food Addiction Scale or YFAS [2–3]. Before this questionnaire, there was no standard way of measuring “food addiction” [2]. This is the idea that people experience the same symptoms of drug addiction, including withdrawal, when eating a lot of highly processed foods that are high in fat and sugar, like ice cream, cookies, chips, burgers, and sugary drinks [4]. Examples of food withdrawal include experiencing irritability, sadness, headaches, fatigue, difficulty concentrating, or cravings when eating less of these foods.
Although food addiction is not an officially recognized disorder among scientists, the idea is not new. Some people do identify themselves as a “food addict” [5] and might join self-help programs such as Overeaters Anonymous, which has existed since 1960 [6]. Additionally, food addiction does appear in the media [7–8]. Symptoms such as overeating are often described, but others such as withdrawal are overlooked. Given this long history, do we have the evidence to back up the idea that people can experience food withdrawal?
What does the science say about food withdrawal?
The research on food withdrawal is mostly limited to animal studies, anecdotes among humans, and responses to the YFAS. One review of studies published in 2009 found that when rats were fed a diet of sugar and this food source was removed, the rats displayed symptoms similar to heroin withdrawal, such as aggression, teeth chattering, paw tremor, and headshaking [9, 10, 11]. In a more recent review of studies published in 2018, again only animal studies were discussed in the context of withdrawal [3]. The authors noted that given that the body’s responses to food are smaller than those to drugs, withdrawal symptoms might be present but not as noticeable in humans.
Reports of sugar and other processed food withdrawal among humans, such as headaches and fatigue, have largely come from observations of people cutting back on these foods or from self-help books and websites [10, 12, 13, 14]. Although this anecdotal information is important, it has not been observed under controlled scientific conditions [10]. As a result, it is unclear if the withdrawal symptoms are a result of abstaining from certain foods, or if they are due to other factors, such as other lifestyle changes. An example of a controlled study would be randomly assigning individuals with food addiction to either: 1) abstaining from eating certain foods, or 2) not abstaining, and observing both groups over a period of time, perhaps in a controlled laboratory setting. If withdrawal symptoms emerge for the first group and not the second, then this would suggest that the withdrawal is caused by abstaining from certain foods, assuming that this is the one main variable that differed between the two groups.
Lastly, the research team behind the YFAS [15] pointed out that 19-30% of people in the community [4, 16] and 26-55% of patients with eating-related issues [17–18] who completed the YFAS did report withdrawal symptoms. However, like the anecdotal information, these studies were not experimental and so these withdrawal symptoms could be related to other factors.
Developing a questionnaire to measure food withdrawal
Recognizing that there was no standard way to measure food withdrawal in humans, the research team behind the YFAS developed and tested the Highly Processed Food Withdrawal Scale or ProWS [15]. A total of 231 online participants who attempted to cut down on highly processed foods in the past year completed the ProWS. They were asked when four symptoms (described below; see Figure 1 for two of the symptoms) were at their most intense following the cutting back attempt. These symptoms were chosen because they are seen in withdrawal across most drugs of abuse [1, 15].
Figure 1: Reported time course of two food withdrawal symptoms. Adapted from Schulte et al. (2018). This is the author’s interpretation of the general patterns observed. Interested readers can find the full figure in the original article.
The researchers found that overall, 55% of participants reported having cravings, 35% felt irritable, 27% felt tired, and 27% felt down after cutting back. These symptoms peaked after 2-3 days, except for sadness, which was at its worst after 4-5 days (see Figure 1). The authors mentioned that this pattern is similar to what might be seen with withdrawal from marijuana and cigarettes [19–20] and provides early evidence for withdrawal from highly processed foods [15]. This information may even help healthcare providers who are helping people cut back on processed foods, as clinicians can give information about withdrawal symptoms, set expectations for how long they last, and suggest strategies to manage them [15].
However, this early study is limited because it does not report how many people experienced more physical symptoms such as nausea, night sweats, hot flashes, and headaches [15]. Furthermore, because scientists have not identified a specific substance or ingredient that is addictive across different foods [21], withdrawal symptoms may actually vary depending on the food. For example, eating less candy might lead to different physical effects, such as low blood sugar, that you may not see if you ate less cheese [15]. Additionally, given that the dieting attempt could have been at any time in the past year, participants may not have always remembered accurately [15]. Using biological tests (for example to measure stress hormones) might provide more objective evidence of withdrawal symptoms [15]. Future studies will need to look at how withdrawal symptoms unfold in real-time, in controlled laboratory settings, and using other measures.
What can we say about food withdrawal at this time?
To return to the question of whether or not we experience withdrawal symptoms from cutting back on certain foods, the answer is maybe. The limited evidence we have points more to psychological symptoms, such as cravings, and not physical symptoms, such as nausea. However, psychological symptoms are still incredibly impactful. In fact, there are few physical symptoms when withdrawing from substances such as tobacco [1, 15]. If someone you know has tried to quit smoking, you know how irritable or anxious they can get right after quitting!
Erfurt (2017). Photograph of a person with their hands on their face.
Why is understanding food withdrawal important? Some theories about how people develop addictions depend on the idea that people use substances (or in this case, eat food) in order to feel relief from unpleasant withdrawal symptoms that develop after using that substance repeatedly [22]. These theories are called negative reinforcement models of drug motivation [22]. For these theories to apply to food addiction though, we still need a better understanding of withdrawal from food or we need to consider other theories. Negative reinforcement models within the past 20 years have now been expanded to focus more on psychological rather than physical withdrawal symptoms, as well as unconscious motivations resulting from learning repeatedly that use results in relief [22, 23]. Substance use may also be about escaping distress from one’s environment, and not just distress due to withdrawal symptoms [22]. For example, you may grab that ice cream after work because of cravings, because of habit, or because you had a stressful day. Given the limited evidence of food withdrawal, these other factors may be more relevant to developing food addiction. Regardless of the source of distress, drug-induced or environmentally prompted distress may result in similar internal cues in the body that can trigger substance use [22].
Another theory is the incentive sensitization theory of addiction [24]. This theory argues that the brain has two separate but related systems responsible for “liking” (pleasure) and for “wanting” (called incentive salience) [24, 25]. This “wanting” is an unconscious desire for rewards and cues that signal these rewards [25], such as fast food and fast-food advertising. Seeing such a cue may motivate someone to get in line for a burger. This model suggests that with repeated drug use, the brain changes such that processes responsible for “wanting” drugs become more sensitive [25]. Research shows that one can “want” something without “liking” it and vice-versa [25]. It appears that drugs of abuse, food, and gambling can hijack our “wanting” system; that is, “wanting” can increase and “liking” may stay the same or even decrease [25]. Tolerance to a drug occurs when it is no longer pleasurable, and it can lead to escalation of drug use as one searches for that initial pleasure [25]. Processed foods may trigger initially strong “liking” and “wanting” responses, resulting in overeating, which can further increase “wanting” of these foods and their cues [25]. Human and non-human animal research appears to support this theory when applied to food [25] and substances such as alcohol [26]. Given the currently limited evidence for food withdrawal, the incentive sensitization theory may better explain food addiction when compared to negative reinforcement models.
Understanding what is driving food addiction is important for creating effective treatments and policies related to eating, which is why more research is needed before making any conclusions and recommendations. It is also important to remember that research on food addiction and withdrawal is still in its early stages. The YFAS was published in 2009, the ProWS was published in 2018,and the ProWS for children was published in 2020 [2, 15, 27]. With more research, we will hopefully better understand if and how people experience withdrawal symptoms when cutting back on certain foods. At the moment, it is unclear but there is some promising evidence!
You are still unsure if you have a problem with ice cream or not… Maybe the craving was not so much an effect of not eating ice cream but other things, like seeing the ice cream shop sign, having a stressful day at work and usually eating to relax, or something outside your awareness. Who knows! You think, “Maybe if I ride this craving out, it will go away. Let me do something else relaxing like read that book at home instead.”.
Resources
If you are wondering if you have food addiction symptoms, the YFAS and ProWS, the questionnaires of food addiction and food withdrawal discussed in the article, are freely available by the researchers here. However, if you are experiencing eating-related issues that are distressing for you, it may be helpful to talk to your doctor, as there are mental health professionals who can assess and treat eating disorders. For a description of eating disorders, treatments, and resources, visit the Canadian Mental Health Association, Ontario Division.
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