Technological-enhanced treatment of emotional eating in obese subjects:

1. Technological-enhanced treatment of emotional eating in obese subjects: A randomized controlled clinical trial Alessandra Gorini Mauro Manzoni, Francesco Pagnini, Gianluca Castelnuovo, Enrico Molinari, Giuseppe Riva Applied Technology for Neuro-Psychology Lab Istituto Auxologico Italiano, Milan, Italy

2. AIMS OF THE STUDY Goal of the study: evaluate the IMMEDIATE and LONG TERM efficacy (6-month follow up) of a technological based clinical protocol for the management of emotional eating in obese subjects. Clinical aim: help obese subjects to cope and manage negative emotions that usually provoke emotional eating episodes.

3. OBESITY Obesity is a medical condition characterized by overweight (BMI>30) (WHO, 2003). Obesity is a biopsychosocial pathology, caused by complex and dynamic system of biological, social and psychological factors.

4. EMOTIONAL EATING (1) Definition Eating an unusually amount of food in response to negative (or positive) emotions instead of in response to physiological needs INAPPROPRIATE COPING MECHANISM: Excessive eating is used to reduce distress (Kaplan and Kaplan, 1957: psychosomatic theory of obesity)

5. EMOTIONAL EATING (2) Overweighted and obese people tend to eat more food in response to emotions than normal-weighted individuals (Ganley, 1989) WHY? • Dysfunctional brain metabolism (serotonin) • Behavioural factors: association between food and release of anxiety (Canetti, 2002).

6. EMOTIONAL EATING (3) Emotional eating is a dysfunctional eating behaviour that affects many obese people (Masheb and Grilo, 2005). It seems to be a component of binge eating and Binge Eating Disorder (BED) Even if we cannot sustain that emotional eating is implicated in the aetiology of obesity, we can say that in many cases it contributes to its maintenance and increase.

7. A NEW TREATMENT PERSPECTIVE • If stress and negative emotions are critical factors that may induce overeating, then psychological and behavioural interventions for obese patients with emotional eating should include stress management and emotion-shifting strategies, together with the traditional CBT

8. HOW TO REDUCE STRESS • Stress management can be achieved by relaxation BUT • Relaxation is difficult to be achieved and usually takes a long time to be learned

9. AIM OF THE STUDY • Evaluate the effect of a three-week relaxation training protocol partially provided through a relaxing VR environment and supported by portable mp3 players on stress and negative emotions in a sample of obese female patients with emotional eating.

10. METHODS Participants 60 female in-patients (Mean age=42; SD=8,6) meeting the WHO criteria for morbid obesity (BMI  30) Score 1 in the Emotional Overeating Questionnaire (EOQ) Experimental design 3 conditions: - VR - IMAGINATIVE - WL

11. TREATMENT (IN-PATIENT PROGRAM) • 5 weeks medically-managed residential program consisting in a moderately low-calorie diet, physical training, psychological support and participation in nutritional groups PLUS…

12. 1° week: 3 non-immersive VR sessions (narrative only) + mobile sessions • 2° week: 3 immersive VR sessions + mobile sessions • 3 week: 3 immersive stressfull VR sessions + mobile sessions

13. THE VIRTUAL ENVIRONMENT (1) The Green Valley (NeuroVR 1.5) was used in order to enhance relaxation by visually presenting key images for facilitating the process

14. THE RELAXING NARRATIVES • A combination of Progressive Muscular Relaxation (muscolar tension) and Applied Relaxation (coping strategies)

15. THE VIRTUAL ENVIRONMENT (2) A buffet in a restaurant was used in order to expose patients to a common stressful situation teaching them how to cope with stress

16. MOBILE SESSIONS Subjects included in the VR and IM groups were given an mp3 player in order to practice, at least once a day, the relaxation techniques learned during the therapist’s assisted sessions

17. COLLECTED VARIABLES First session: EOQ (Emotional Overeating Questionnaire) First and last sessions: WELSQ (Weight efficacy life style questionnaire) BDI (Beck Depression Inventory) Before and after each treatment sessions: STAI(State Anxiety Inventory) VAS (Visual Analogue Scale) Heart rate was also recorder (psychophisiological assessment)

18. RESULTS (SHORT TERM) • Pre vs post treatment (BDI)

19. RESULTS (SHORT TERM) • Pre vs post treatment (WELSQ)

20. RESULTS (SHORT TERM) • Pre vs post sessions • Significant decrease of state anxiety (STAI) and significant increase of relaxation (VAS-R) before and after each treatment session both in the VR and in the IM groups, while no differences were found between them • Significant decreases in heart rate values both in the VR and IM groups after each session. • The same results were found when patients were exposed to the stressful environments (last week of treatment)

21. RESULTS (6-MONTH FOLLOW UP) • 36 patients (12 VR, 14 IM and 10 WL) • At follow up, VR and IM groups show a significant higher score on WELSQ and lower scores on BDI than WL

22. CONCLUSIONS • A brief relaxation training (12 sessions in 3 weeks) based on the use of VR + mp3 or mp3 alone increased the perceived self-efficacy for eating control and reduced the depression level in both the experimental groups • Regarding the within sessions effects, the relaxation training was effective in reducing state anxiety and in increasing the relaxation level, in the two groups of patients • Results have been mainteined at 6-month follow up

23. THANK YOU FOR YOUR ATTENTION! a.gorini@auxologico.it