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Obesity

Obesity. Epidemiology of Obesity. Definition/Prevalence Medical Complications Social and Psychological Consequences. Key Prevalence Facts. Overall rate of obesity is 34.8% Rates have risen significantly (25.4 vs 34.8) Overall men and women do not differ much (men 33.7-women 35.9)

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Obesity

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  1. Obesity Eating Disorders

  2. Epidemiology of Obesity • Definition/Prevalence • Medical Complications • Social and Psychological Consequences Eating Disorders

  3. Key Prevalence Facts • Overall rate of obesity is 34.8% • Rates have risen significantly (25.4 vs 34.8) • Overall men and women do not differ much (men 33.7-women 35.9) • Rates increase with age up to age 64 and then decline • Rates significantly higher among black and Hispanic females (see table) Eating Disorders

  4. Eating Disorders

  5. Epidemiology of Obesity • Medical complications: • Increases risk for • Heart disease and stroke • Certain forms of cancer • Diabetes • Contributes to other known risk factors • Elevated serum cholesterol • Hypertension • Physical inactivity Eating Disorders

  6. Epidemiology of Obesity • Social and psychological consequences • Social prejudice (more pronounced for women) • Job discrimination • Low self-esteem, depression, anxiety* Eating Disorders

  7. Epidemiology of Obesity • Genetics of obesity • Adoption studies • Twin studies Eating Disorders

  8. Energy Balance Model of Obesity Caloric Intake – Caloric Expenditure + (Weight Gain) - (Weight Loss) Eating Disorders

  9. Energy Balance Conceptualization of Obesity • Calorie input • Intake of liquid and solid foods • Calories out • Basal metabolic rate (BMR) • Exercise • Food-related thermogenesis • Exercise-related thermogenesis Eating Disorders

  10. Assessment of Obesity • Body weight based on gender and height • Percent body fat • Skin-fold thickness • Underwater weighing • Electrical impedance • Body mass index (BMI) Eating Disorders

  11. Medical Treatments for Obesity • Pharmacotherapy • Appetite suppressants (Fenfluramine) • Stimulants (Ephedrine)* • Opiate antagonists (Naltrexone) • Other medical procedures • Stomach stapling • Medically-supervised low calorie • Liposuction Eating Disorders

  12. Psychological Treatments for Obesity Eating Disorders

  13. Evolution of Behavioral Treatments for Obesity • First Generation • Second Generation • Third Generation Eating Disorders

  14. Cognitive-Behavioral Treatments for Obesity • Self-monitoring • Stimulus control • Goal setting • Reinforcement • Education • Cognitive restructuring • Nutritional education • Exercise prescriptions • Relapse prevention training Eating Disorders

  15. Limitations of Behavioral Treatment Research • Studies do not last long enough to get patients to goal weight • Inadequate comparison groups • Inadequate follow-up Eating Disorders

  16. Improving Long-term Weight Loss • Better screening • Longer programs • Incentive systems for increasing adherence • Social support • Treatment matching • Relapse prevention strategies • Integration of “non-behavioral” treatments Eating Disorders

  17. Bulimia Nervosa Eating Disorders

  18. Diagnostic Features • A. Recurrent binge eating • B. Recurrent inappropriate compensatory behavior in order to prevent weight gain • C. Binge eating and compensatory behavior occur at least 2/wk for 3 months • D. Self-evaluation is unduly influenced by body shape and weight • E. Exclude the diagnosis if the symptoms occur exclusively during episodes of anorexia nervosa Eating Disorders

  19. Essential Features of Binge Eating • Large amount of food consumed in a small amount of time (< 2 hours) • During the eating episode there is the distinct feeling of being out of control over one’s eating Eating Disorders

  20. Epidemiology of Bulimia Nervosa • Prevalence • 2.8 to 5.5% (Kendler et al, 1991) • 4 % (Rand & Kuldau, 1992;Whitaker et al, 1990) Eating Disorders

  21. Epidemiology of Bulimia Nervosa • Etiology • Genetic factors Eating Disorders

  22. Stice Dual Pathway Model Pressure to Dieting be thin .17*** .38*** Body Bulimic .14^ dissatisfaction symptoms .25* .20** Thin-ideal Negative internalization affect Eating Disorders

  23. Risk Factors for Bulimia • Social pressures to be thin • Perceived pressure fro thinness is correlated with bulimic pathology (Stice et al., 1996) • Perceived pressure fro thinness predicts future bulimic symptoms (Stice et al., 2000) • Experimental exposure to thin-ideal images increases negative affect and body dissatisfaction (Stice & Shaw, 1994) Eating Disorders

  24. Risk Factors for Bulimia • Internalization of the thin ideal • Bulimics are more likely to endorse the thin ideal than non-bulimics (Williamson et al, 1993) • Internalization of the thin ideal is associated with bulimic symptoms (Stice et al., 1994) • Internalization of the thin ideal predicts future bulimic symptoms (Kendler et al, 1991; Joiner et al., 1997; Stice et al, 2000) Eating Disorders

  25. Risk Factors for Bulimia • Elevated body fat (adiposity) • Body Mass Index correlated with bulimic symptoms (Stice et al., 1996) • Body Mass Index predicts future body dissatisfaction (Stice et al., 2000) • Body Mass Index predicts onset of subclinical eating pathology (Killen et al., 1994) Eating Disorders

  26. Risk Factors for Bulimia • Body Dissatisfaction • High body dissatisfaction is correlated with bulimic symptoms (Ruderman & Besbeas, 1992) • Body dissatisfaction predicts future bulimic symptoms (Leon et al, 1993; Killen et al., 1994; Stice et al., 1994) • Experimentally-induced reduction in body dissatisfaction led to decreased binge eating relative to baseline (Rosen et al, 1990) Eating Disorders

  27. Risk Factors for Bulimia • Negative Affectivity • Bulimics show greater concurrent mood disturbance than controls (Ruderman & Besbeas, 1992) • Negative affect predicts future bulimic symptoms (Stice et al, 1999) • Bulimics report more negative affect prior to binges than when eating normally (Davis et al, 1988) • Experimentally inducing negative affect triggers overeating among restrained eaters (Cools et al, 1992; Telch & Agras, 1996) Eating Disorders

  28. Risk Factors for Bulimia • Dieting (Restrained Eating) • Bulimics show greater concurrent mood disturbance than controls (Ruderman & Besbeas, 1992) • Dieting predicts future bulimic symptoms (Kendler et al, 1991;) • Dieting predicts onset of subclinical eating pathology (Killen et al., 1994) • Experimentally-induced caloric deprivation leads to disinhibitory eating (Telch & Agras, 1996) Eating Disorders

  29. Epidemiology of Bulimia Nervosa • Associated Conditions (Co-morbidity)* • Alcoholism (3.2) • Phobias (2.4) • Depression (2.2) • Anorexia Nervosa (8.2) • *Borderline Personality Disorder Eating Disorders

  30. Epidemiology of Bulimia Nervosa • Course Eating Disorders

  31. Pharmacotherapy for Bulimia Nervosa • Tricyclic Antidepressants Eating Disorders

  32. Pharmacotherapy for Bulimia Nervosa • Tricyclic Antidepressants • SSRI’s • d-fenfluramine Eating Disorders

  33. Pharmacotherapy for Bulimia Nervosa • Tricyclic Antidepressants • SSRI’s • Fenfluramine • Phenelzine Eating Disorders

  34. Cognitive Model of Bulimia Eating Disorders

  35. Restraint Theory(Herman & Polivy, 1985) • Major assumptions of the model • Sociocultural factors leads to dietary restraint • Dietary restraint increases risk of binge eating • A variety of factors may operate as disinhibitors of restrained eating thus leading to counter-regulatory eating (binge eating) • Cognitive factors play a central role in counter-regulatory eating Eating Disorders

  36. Types of Disinhibitors • Preload • Alcohol • Depression • Anxiety • Perceived caloric content of a food Eating Disorders

  37. Cognitive-Behavioral Treatments for Bulimia • Self-monitoring • Exposure plus response prevention • Stimulus control/environmental change • Training in specific coping skills • Cognitive-restructuring • Dietary counseling Eating Disorders

  38. Controlled Outcome Studies for Bulimia • Kirkley et al (1985) • Fairburn et al (1986) • Agras et al (1989) • Fairburn et al (1993; 1995) • Walsh et al (1997) • *Agras et al (2000) Eating Disorders

  39. Agras et al (2000) Eating Disorders

  40. Agras et al (2000)Study Overview • 220 patients meeting DSM-III-R criteria for bulimia nervosa were randomized to CBT or IPT in a multisite • 19 individualized weekly sessions • Evaluated outcome at posttreatment and at a 12 month follow-up) • High attrition (28% CBT vs 24% IPT) Eating Disorders

  41. Agras et al (20000Intent-to-Treat Findings Eating Disorders

  42. Moderators of Treatment Outcome • Lower weight or Body Mass Index (Wilson et al, 1986; Agras et al, 1987) • Self-esteem (Fairburn et al (1987) • Binge frequency (Garner et al, 1990) • Personality pathology (Johnson et al, 1990; Rossiter et al, 1992) • Naturalistic Investigation of Eating Behavior in Bulimia (Davis) Eating Disorders

  43. Binge Eating Disorder Eating Disorders

  44. Diagnostic Features of Binge Eating Disorder • Recurrent episodes of binge eating • Perceived loss of control over eating • Frequency of at least 2/wk for 6 mos. • Binge eating causes marked distress • Binge eating does not occur exclusively during the course of bulimia nervosa Eating Disorders

  45. Epidemiology of Binge Eating Disorder • Prevalence Eating Disorders

  46. Associated Features of Binge Eating Disorder • Elevations on indices of restrained eating (McCann et al, 1990) • Increases with obesity (Telch et al, 1988) • Elevations on indices of psychological distress (Kolotkin et al 1987; Marcus et al, 1988) • Elevations on indices of depression (Marcus et al, 1988) • Higher lifetime prevalence of major depression (Hudson et al 1988) • Higher prevalence of BPD and panic disorder (Yanovski et al (1992) Eating Disorders

  47. CBT for Binge Eating Disorder Eating Disorders

  48. Procedural Components of CBT for Binge Eating Disorder • Treatment rationale • Self-monitoring • Altering patients’ meal consumption • Relapse prevention training Eating Disorders

  49. Controlled Outcome Studies for Binge Eating Disorder • Telch et al (1990) • Wifley et al (1993) • Agras et al (1994) Eating Disorders

  50. C.Telch et al (1990) Eating Disorders

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