To Eat or Not to Eat is that Really the Question?

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1 To Eat or Not to Eat is that Really the Question? Consideration of Problematic Eating Behaviors Lisa Matero, PhD

2 Overview Discuss problematic eating behaviors Connections with mental health Effects on weight How to identify these behaviors Strategies to help patients manage problematic eating behaviors

3 How often do we think about food?

4 Over 200 food decisions made daily! Wansink & Sobal (2007)

5 Why are patients obese? Nature vs. Nurture Trauma/Abuse Variety of types (witnessing, bullying, physical, emotional, sexual) Especially occurring in early childhood/adolescence Psychiatric Illness Problematic eating patterns Binge eating Cravings Emotional eating Food addiction

6 Binge Eating Disorder Now recognized in the DSM-V Binge eating episode: Consuming large portions Loss of control Once per week; over 3 months

7 Binge Eating Disorder Associated with (3+): Rapid eating Feeling uncomfortably full Not physically hungry Eating alone because of embarrassment Negative emotions after (e.g., disgusted with oneself, depressed, or guilty) No purging/compensatory behaviors

8 Binge Eating Disorder Severity Mild: 1 3 binge-eating episodes per week Moderate: 4 7 binge-eating episodes per week Severe: 8 13 binge-eating episodes per week Extreme: 14 or more binge-eating episodes per week Prevalence BED = 2.8% Subthreshold = 1.2% Any BE behavior = 4.5% More likely to struggle with excess weight Prevalence = 10-30%

9 Cravings Definition minutes Sweets, starches, salty, fatty Prevalence 97% - female Only 32% attributed to PMS 68% - men Higher BMI linked to more cravings Rodin et al., 1991 Weingarten & Elston, 1991

10 Emotional Eating Eating in response to emotions Negative & positive emotions Sweets, starches, salty, fatty Stress! high carb, high fat Drugs: stress! relapse Blumenthal et al., 2010 Corsica & Pelchat, 2010 Ifland et al., 2009

11 Emotional Eating Quite common is this actually a problem? Not recognized as a disorder Recommendations Frequency Impact on weight Impact on life

12 Obesity: A Choice or an Addiction? Controversial Debate: People may become addicted to food in a similar manner as people become addicted to other substances Common: sweets, carbohydrates, fat, salt

13 Food Addiction Similar to substance dependence Criteria 1. Consumed more and for longer period than intended 2. Persistent desire or repeated unsuccessful attempt to quit/ cut down 3. Much time/activity to obtain, use, recover 4. Important activities given up or reduced 5. Use continues despite adverse consequences 6. Tolerance 7. Withdrawal symptoms/prevent withdrawal **Clinically significant impairment or distress

14 Criteria Tolerance Consuming greater quantities to have same effect Binge episodes: Increase in amount, frequency, and duration Emotional eating episodes: Increase I kept a bag of dark chocolate candy in the pantry. I started out eating one serving per day. Then, I started putting an extra serving in my lunch bag. Then I would add another piece or two at breakfast. It just got worse and worse. Gearhardt et al., 2009 Ifland et al., 2009

15 Criteria Withdrawal Evidence in animal models Humans - anecdotal Carbs! low energy, palpitations, headache, sweats Salt! nausea Process similar to withdrawal in drug addiction: Food restriction! Exaggerated cephalic response! Hypoglycemia! Intense cravings and hunger I eat sugar filled foods to correct being tired and/or depressed I am afraid if I stop using food to correct my emotions, I will feel tremendous fear and anger. Gearhardt et al., 2009 Ifland et al., 2009

16 Animal Studies Experience tolerance to glucose Decrease in temp & behavioral changes (withdrawal); Increase in calories (relapse) Obese vs. normal weight Lower baseline levels of mesolimbic dopamine activity Palatable foods! dopamine Blumenthal et al., 2010 Ifland et al., 2009 Schulte et al., 2015 Wideman et al., 2005

17 Human Studies fmri Food & drug cues Activate: OFC, amygdala, insula, striatum Food & drug cravings Changes in hippocampus Obese pts with gastric stimulation! activates cortical and limbic regions PET Decreased striatal D2 receptor availability & levels negatively correlated with BMI Decreased sensitivity of reward system Reinforces food consumption Blumenthal et al., 2010 Corsica & Pelchat, 2010 Pelchat et al., 2009

18 Human Studies Food addiction scores & receipt of food Positive correlation with scores Greater activation: amygdala, medial OFC, anterior cingulate cortex Higher vs. lower scores: Greater activation: dorsolateral prefrontal cortex and caudate Less activation in the lateral OFC Patterns similar to drug addiction Gearhardt et al., 2011

19 Obesity: A Choice or an Addiction? Against food as an addiction: DSM-V Does not recognize food as addiction Other research Insufficient evidence

20 Against Addiction The addictive foods are not defined Broad, imprecise No convincing human evidence for tolerance and withdrawal Imaging studies are correlational and not consistent Possibility that obesity is cause of neuroanatomical differences Ziauddeen & Fletcher, 2012 Ziauddeen et al., 2012

21 Against Addiction Abnormal addiction Difficult to determine meaningful impairment Food is necessary for survival Rise in obesity is linked to rise in food availability Ideas are not consistent across studies Ziauddeen & Fletcher, 2012 Ziauddeen et al., 2012

22 Rebuttal Inconsistencies Obesity is heterogeneous Individual differences Critiques similar to early criticisms of tobacco Accessible, socially permissible, legal Food is necessary for survival Components of food not necessary Example of water in beer Premature to reject Deserves further study Avena et al., 2012 Schulte et al., 2015

23 Consequences of Labeling Pros Increased research Develop treatments Treatments covered by insurance Opportunities to improve health Cons Broad perspective is not sustainable Difficult to research in current state Overpathologize Cop out

24 Prevalence Few studies Food Addiction: 8-42% Among bariatric candidates: Binge eating behaviors: 15.5% Food addiction: 17%; 43%; 98.6% Emotional Eating Anger/frustration: 25.4% Anxiety: 40.7% Depression: 38.4% Overall score: 38.1% Possibility of low estimates Miller-Matero et al., 2014

25 Relationships Among Problematic Eating Behaviors Emotional eating! Emotional eating Food addiction! Emotional eating Food addiction & Emotional eating not related to BMI All patients were morbidly obese Miller-Matero et al., 2014

26 Comorbidity with Mental Health Meta-analysis Prevalence 19% depressed (8%) 17% binge eating (1-5%) Improvements post-surgery 6 & 12 months Mixed results for post-surgery weight loss Dawes et al., 2016

27 Comorbidity with Mental Health Depression Anxiety Food Addiction Anger/Frustration Anxiety Depression Overall Emotional Eating Blue values: p <.05 Red values: p <.01 Miller-Matero et al., 2014

28 Outcomes Post-Surgery Depressive and anxiety symptoms were not related to %EWL (p>.05) Emotional eating! Lower %EWL Anger/frustration (p=.02) Depression (p=.05) Binge eating! Lower %EWL (p=.06) Food addiction symptoms! Weight regain (p=.01) Miller-Matero, APM 2016

29 How can we help? Identification Behaviors Triggers Available treatments

30 Providers Miss Diagnoses 1. Being overweight/overeating is common 2. Emotional eating is normal 3. These are not actual diagnoses 4. Unsure what to do with these patients 5. Eating behaviors are not a typical part of an appointment

31 Key Questions to Ask Patients may report: Fatigue/sluggish, request for medications, repeated unsuccessful attempts to lose weight, continuous increase in BMI over time If suspect a problem: Do you ever lose control over your eating? Do you continue to eat even when you feel full? Do you feel addicted to food? Is food the first thing you turn to when you feel stressed, depressed, bored, angry? Do you often eat when you are not hungry? Have you tried multiple times to lose weight without success? Do you experience stress, anxiety, or guilt when you eat?

32 Screening Tools To help you recognize a problem: Eating Attitudes Test Most widely used Binge Eating Scale Yale Food Addiction Scale Emotional Eating Scale

33 Treatments Binge Eating Weight loss program vs. Binge eating treatment Binge eating treatment! Greater long-term WL success CBT Little evidence for pharmacology Sibutramine, topiramate Multidisciplinary approach Medications, psychotherapy, nutritional guidance

34 Treatments Overeaters Anonymous 12 step program Patients reports = helpful Food Addiction & Emotional Eating Little known CBT? Richards et al., 1997 Russell-Mayhew et al., 2009

35 Treatments Weight Assistance and Intervention Techniques (WAIT) Group 1) Introduction / Increase Motivation 2) Problematic Eating Behaviors 3) Mindful Eating and ACT 4) Self-sabotaging Talk 5) Overcoming Challenges 6) Maintaining Motivation / Getting Back on Track

36 WAIT Group Success From pre- to post-group, there were significant decreases in: BMI (t = 7.04, p <.001) The number of food addiction symptoms reported (t = 2.25, p = 0.05) APM, 2015

37 WAIT Group Success APM, 2015

38 Summary Many problematic eating behaviors are not recognized as disorders Growing evidence Problematic eating behaviors are easily missed Providers do not know what to ask Behaviors are considered normal Behavioral health providers can assist with problematic eating behaviors

39 Future Directions Establish problematic eating as diagnoses Investigate whether problematic eating behaviors affects weight loss success Develop and examine other treatments The debate will continue!

40 When you are addicted to drugs you put the tiger in the cage to recover; when you are addicted to food you put the tiger in the cage, but take it out three times a day for a walk Overeaters Anonymous

My Weight (Assessment)

My Weight (Assessment) Which of the following describes you? o I know I need to lose weight but I m not quite ready to start. o I m ready to lose weight and I need some help. o I want to maintain my weight