4/26/2019
1
Rita Lynn Panizzon: Ritalin; Methylphenidate
(Schartz ‘16)
• 1940:ChemistLeandroPanizzon
• Tinkeredwithmolecular
structureofthestimulant
amphetamines
• Developedadrugthatturned
hiswifeintoatennisplaying
machine
• In1956thedrugwasapproved
totreaterraticbehaviorin
adults.
Overcoming Obstacles in the Treatment of Loss of Control
Eating: Strategies for Identifying & Treating Patients
Little Rock, Arkansas
April 25, 2019
RalphECarson,RD,PhD
NutritionistandExercisePhysiologist
SeniorClinicalandResearchAdvisor,ERCandBETR
Outline: Evidenced-based Treatment of Loss of Control Eating
• Philosophy&Focus
• StratificationofLOCeating
• Biopsychosocialmodel
• Genetics
• NeurophysiologicalModel
• Roadblockstoseeking
treatment
• Pharmacology
• Psychotherapy
• Chronobiology
• Nutrition
• Sleep
• Joyfulmovement
• Referringtohigherlevelofcare
• MinglingBEDandAN
• Customizingenvironmentand
treatment
4/26/2019
2
Philosophy
(Chastain ‘18)
• DeclarationofIndependence
• Theserightsarenotsize
dependent
• Peoplehavetherighttoexistin
bodiesofallsizeswithout
• Shame
• Stigma
• Bullying
Focus
(Saguy ‘13;Flegal ’08;‘13;Lavie ’14;Brown’15;Shoaib’16;Afsal ‘16)
• Focusisonbeingmetabolically
sound
(Saguy ‘13)
• Notaboutbodysizeorbodysize
manipulation
• Beingmetabolicallysoundisnot
entirelywithinourcontrol
• Recognizethatsocialdetrimentis
arisktohealth
• Respectfuloflanguage
• Peopleofhigherweight
• Largerbodied
• Whateversomeoneprefers
Opposition to the Diet Culture
(Barrett & Gurin ’83)
• Don’tpromotedietsasapath
tohealth,acceptanceor
privilege
• Dietsdon’twork
• <5%successrate
• Thegoalistochangebehaviors
wecancontrol
• Notbyattemptingtomanipulate
bodysize
• Avoidperpetuatingeating
disorders
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3
Loss of Control Eating Disorders
(Ross’09;’16;Roth‘93;Mintle ‘02)
BingeEatingDisorder(BED)
BulimiaNervosa(BN)
OSFED
BEDoflowfrequencyand/or
limitedduration
NightEatingDisorder
Post‐ BariatricSurgeryCare
Compulsiveovereating
EmotionalEating
BED is REAL
(APA DSM-V May 2013)
• Categorizedasaneating
disorderdrivenby
• Lossofcontrol
• Experiencingsignificantdistress
• Frequency&Duration
• Grazingratherthanobjectively
consumingalargevolumeof
food
• Bulimianervosa
• Associatedwithcompensatory
behavior
Prevalence of Binge Eating Disorder
• 2.6%to5.5%ofadultshaveBED
(Hudson’07;Kessler’13;Darby’09;APA‘13;
Marcus‘05)
• GreaterthanAN&BNcombined
• NationalEpidemiologicalSurvey
Alcohol&RelatedConditions
(Udo&Grillo‘18)
• Expectedlowerafterloosening
DSM‐Vcriteria
• Only3.2%reportevery
receivingadiagnosisofBED
fromahealthcareprovider
(Crossrow ‘16)
0.8%
12.7
million
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4
Relationshipdistressandimpairedsocialrolefunctioning
(Kessler’13,‘14;Whisman ‘12)
Misswork,socialactivities&familyresponsibilities
(Javaras ‘08;Kessler’14;Whisman ’12:Hudson‘07)
Isolatetoavoidembarrassment,guilt,shame
(Javaras ‘08;Kessler’14;Whisman ’12:Hudson‘07)
Crosssensitivity
(Stice ’13;Guerdjikova ’12;Allen’13)
Poorqualityoflife
(Agh ’16;DeJong‘13;Baiano ’14:Mond‘05)
Medicalcomplicationsnotrelatedtobeingahigherweight
BED,Stigma,Trauma
Behavioral & Health Consequences Associated with BED
LOC: 80% Psychological Co-morbidities
(Halmi ’10;Johnson‘01;Kaye‘04;McElroy’05;Hudson’07;Larsen‘04;
Tanofsky‐Kraff ’09;
White’06;Javaras ‘08;Kessler‘13
)
Majordepressivedisorder BorderlinePersonalityDisorder
AnxietyDisorder BipolarDisorder
PTSD BodyDysmorphicDisorder
ADHD SubstanceAbuse&Dependence
OCD SleepDisorders
ASD
Night Eating Syndrome
(Allison’04)
Eveninghyperphagia
Nocturnalawakening&feeding
3of5mustalsobepresent:
1. Morninganorexia
2. Urgestoeatintheevening
3. Believeeatingisnecessaryto
returntosleep
4. Depressedmoodworsening
intheevening
5. Sleepdisturbances
4/26/2019
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Eating Disorders in Post Bariatric Patients
(Friedman’16;Friere ‘12;Valle’12;Parikh‘07)
• 17%EDinpost‐bariatric
(Dawes‘16)
• PSEAD:PostSurgicalEating
AvoidanceDisorder
(Siegel‘04)
• Grazing,Picking&Nibbling:
20%‐ 60%
(Guarda ‘15;Conceidao ‘13.’15;
Colles‘08;DeZwaan ‘01;Burgmer ‘05;Saunders‘08)
• PluggingorPurging
(Guarda ‘15;
Conceidao ‘13,’15;Sarwer‘05;Kriwanek‘00;
Pessina’01;deZwann ‘10)
• SpittingandChewing
(Conceidao ‘13,
Aouad ‘16)
Impulse Control Disorder: Compulsive Overeating
(Blumenthal‘10,Ziaduddeen ‘13;Sogg ‘07
• Non‐substancerelatedaddictive
disorders(DSM‐V)
• YaleFoodAddictionScale
(Gearhardt ‘09;‘11)
• TriggerFoods
• Healthyrelationshipwithfood
ratherthanabstinence
Compulsive
Compulsive
EmotionalEating BingeEatingDisorder
Notaboutquantity Eatasignificantlylargeamountoffood
Frequencyiserratic Frequency@least1x/wk for3mon
ths
Overeatasaprimaryresponseto
emotionaltriggers
Notnecessarilyeatinginresponseto
emotionaltriggers;Experience
significantstressfollowingbinge
Canleadtobingeeating AdistinctDSM‐VDiagnosis
Troublecontrollingcravingsforfood Troublescontrollingcravingsforfood
Candisruptaperson’slife Candisruptaperson’slife
Eatingwhennothungry Eatingwhennothungry
Differences and overlaps between binge and emotional eating
4/26/2019
6
Inherited
(Predisposing)
Triggers
(
Biopsychosocial)
(Precipitating&
Perpetuating)
Neuro
Alterations
Repair
Therapy
Changesthe
wayyouthink
Nutrition Sleep
Genetics
Environment Cell Loss
Neuro‐
regeneration
CBT
COH
Fiber
Sleep
Hygiene
Traits Dieting
Alterationof
Pathways
Neuroplasticity ERP Ω‐3FA
Circadian
Rhythm
Shift
HPF;
Inactivity
Depletion
Neurotransmitters
Resilience DBT
Fruits and
Veg
CPAP
Stigma
Downregulation
receptors
Collateral
ACT
Protein
Stress
(Cortisol)
Epigenetics Refiling EMDR
Vitamins
Minerals
40% LOC Behaviors Attributed to Genetics
(Seo ’14;Javaras ’08;Mitchell’10;Balodis ’15;Munn’10;Gibson‐Smith‘17;Siaphire‐Bernstein‘11)
FOS
BED
TaqA1
DRD2
Compulsiveeating
MC4R
BED;Hunger
GLUT2 Sugarcravings
Neuro‐
medin
BED;Hunger
LEPR Susceptibletosnacking
5HTTLPR
Emotionaleating
BDNF Exerciseaversion
TAS2R
Aversiontovegetables
OXTR
PoorSocializationSkills
Lowself‐esteem
Etiology: Neurophysiological Alterations
HedonicNeurocircuits Neurohormones Gutpeptides
Insula:Sensoryoverload
(Wang ‘01; ’09)
Orexin:Survival
(Wu‘13;Sakuri
’16;Marzullo ’04;Flores‘13)
PYY,IGF‐1,CCK:Satiety
(Marx
’03;Suzuki‘10’,‘11,’12;Ludwig‘14)
VAT: β-Endorphins &
μ – receptors
(Gosnell ’09;
Bernard ’03; Bello ‘09a)
Hypothalamicinjury:Highly
processedfood
(Thaler ‘12; Wang
‘01; Ozcan ’09, Coll ’07; Kumar ‘14)
GLP‐1:Glucoregulatory
(Mason08,‘13,’15;Dixon‘08)
NAc: Reward receptor
deficiency
(Berthoud ‘11; Wang
‘01; ’09; Blum ‘96;’00)
LeptinResistance:FatStores
(Farooqi’07;Hong‘10;Zhang’10)
Microbiota:Caloricabsorption
(Parekh‘14;Ridaura ‘13;DaSilva‘13)
vmPfC & dlPfC: Free won’t
(Carr ‘11;Volkow’12;Weygandt‘13)
Insulinresistance:VAT
(Bermudez
’16;Ioannou ’07;Hardy‘12)
Responseme:Food→Brain
(Liu’03;Wang‘01;‘09)
Serotonin: Estrogen
(vanStrein ‘10)
Ghrelin:StressAppetite
(Petrovich ’13;Tong‘11;Dickson‘11)
Fullness&Satisfaction
(Puzziferi ‘16)
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7
Hedonic Neurocircuits
• Insula: Sensory overload
(Wang ‘01; ’09)
• VAT: β-Endorphins &
μ – receptors
(Gosnell ’09; Bernard
’03; Bello ‘09a)
• NAc: Reward receptor
deficiency
(Berthoud ‘11; Wang ‘01;
’09; Blum ‘96;’00)
• vmPfC & dlPfC: Free won’t
(Carr ‘11;Volkow ’12;Weygandt ‘13)
• Serotonin: Estrogen
(vanStrein
‘10)
LOC
Neurohormones
• Orexin:Survival
(Wu‘13;Sakuri ’16;
Marzullo ’04;Flores‘13)
• Hypothalamicinjury:Highly
processedfood
(Thaler ‘12; Douglass
‘17; Wang ‘01; Ozcan ’09; Dorfman ’15;
Berkseth ‘14)
• LeptinResistance:FatStores
(Farooqi ’07;Hong‘10;Zhang’10)
• Insulinresistance
(Bermudez’16;
Ioannou ’07;Hardy‘12)
• Ghrelin:StressAppetite
(Petrovich
’13;Tong‘11;Dickson‘11)
Gut Peptides
• PYY,IGF‐1,CCK:Satiety
(Marx’03;
Suzuki‘10’,‘11,’12;Ludwig‘14)
• GLP‐1:Glucoregulatory
(Mason08,
‘13,’15;Dixon‘08)
• Microbiota:Caloricabsorption
(Parekh‘14;Ridaura ‘13;DaSilva‘13)
• ResponseTimeFood→Brain
(Liu
’03;Wang‘01;‘09)
• Fullness&Satisfaction
(Puzziferi ‘16)
4/26/2019
8
Roadblocks to Seeking Appropriate Treatment
I am not sick enough to get help
Embarrassment, Shame, Guilt
Quick fix
Secondary diagnosis
Skepticalthatsimplytalkingwillhelp
Enteringatreatmentfacilityis
overwhelming
Complacentwithoutpatienttreatment
Treatmentburnout
Lisdexamfetamine Vyvance ®
DRI;vmPfC‐
dlPfC;PEA
BED;Control;Reduces
obsession/compulsion
Fluoxetin Prozac® SSRI Emotionaleating
Naltrexone&
Bupropion
Contrave ®
VTA;mu‐
opioid
antagonist
LOC;Cravings
Topiramate &
Phentermine
Qsymia® GABA;cortisol
CompulsiveorEmotional
Eating;Fullness
Fenfluramine Belviq® SSRI;MC4R EmotionalEating;Fullness
Exenatide&
Liraglutide
Byetta®&
Saxsenda®
GLP‐1 Fullness;InsulinResistance
Suvorexant Belsomra®
Orexin‐1R/2R
antagonist
NES;Compulsiveor
Emotionaleating
Evidence Based: Long Term Efficacy
• CBT:1
st
option
(Wilson’05;’10;Vocks ‘10)
• 60%>abstinence
(Hilbert’12)
• DBT:Preliminarysupport
(Telch ‘01;Safer
‘10)
• 89%stoppedBEbytheendoftreatment
• Abstinent@6mos.follow‐up
• ERP:“Sitwithfearslongenoughand
theydissipate”
(Steinglass ‘12;Leitenberg ‘88)
• 54%5yearabstinence
(McIntosh‘11)
• 80%success@decreasingbinging
(Foa ‘10;
Frances‘97)
• ACT:Createafullandmeaningfullife
consistentwithvalues
(Hayes‘82;‘05;‘16;
Harris’08;Codd‘10)
4/26/2019
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Address eating behavior first…mood and anxiety
improvement follows
(Vocks ‘10)
TECHNIQUE
GENTLEEATING
MINDFUL EATING
PACING
HEALTHY CHOICES
INTUITIVEEATING
HUNGER
SATIATION
SATIETY
APPETITIVE
SATISFACTION
EMOTIONAL
PrescribedPatternofRegulated
Eating(PPRE)
Eliminatingdietary“rules”
Calories&measuring
Regulatingresponsesto
“trigger”foods
Avoidingabstinenceor
bingeing
Modifyingemotional&
impulsivedecisionmaking
Structure&pre‐
commitment
Sleep Deprivation: Improving Sleep Quality and Quantity
↓ Leptin
↑ Ghrelin
↑ Cortisol
↑ Cravings & hunger
Sleep hygiene
Circadian Rhythm Shift
Melatonin
Light Therapy
Sleep Restriction
CPAP
Physical Wellness, Joyful movement & Lifestyle Activity
• JoyfulMovement
Fun
Variety
ReducesCortisol
(Creswell
‘13;Oswald‘05;Ahmadzadeh
’06;Mastorakos ’05a,b;
Louvallo ‘08)
• LifestyleActivity
Motionmonitor
Baseline
Customized
Inefficient
• PhysicalWellness
Assessment
Correctiveexercises
Removelimitations
Highertolerancelevel
4/26/2019
10
Temperament Anorexia BED
NoveltySeeking Low High
HarmAvoidance High High
Reward
Dependence
Low High
Persistence High Low
Self‐Directedness Low Low
Cooperativeness Low Low
Self‐transcendence High High
• Neurobiologicalopposites
• Olderpopulation
(Goldschmidt’11;Reas
’07)
• Differentmedicalco‐
morbidities
• Highdropoutrates
(Aguerra ’13;
Wilson‘11;Bulik ‘12)
• Differencesinpersonality
(Cloninger ‘94)
Mingling Treatment for Loss of Control Eating
with Traditional Eating Disorders
Customized Environment and Treatment
• Appropriatefurnishings,
medicaldevices,&exercise
equipment
• Activityconsideration
• Movementrestrictions
• Uniquedietaryneeds
• Separateprogramming
Referring to a Higher Level of Care
Limitedprogression
Cycling
Relapse
Psychologicalco‐morbidities
Medicallyornutritionallyunstable
Suicidal
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11
• Notengaginginpathological
eatingbehavior
• Freefrombingeeatingepisodes
• Healthyrelationshipwithfood
• Notmalnourishedorrestricting
• Reducemetaboliccomplications
• Maximizephysicalcapacity
• Improvesleepquality&
quantity
• Acceptyournaturalbodysize
Confidence&Resilience
EnduringLifeSkills
RecognizeValues
HealthyRelationshipandPeerSupport
Complete recovery is possible
Confidence&Resilience
EnduringLifeSkills
RecognizeValues
HealthyRelationshipandPeerSupport
BelievableHope
Give me your money, then all I have
is your money
But give me your time, and
you give me a part of your life
Thankyou for sharing
a part of your life with me
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12
Sizeism
(McHugh’12;Chrisler ’07;Wolpert‘07;Schapitl ’18;Mann‘07,‘15)
• Sizeism:Thepracticeofthinkingyou
canassessapersonshealthpurely
frombodysize
• Themedicalperspectivethatobesity
isitselfadisease orapsychological
disorder andthatfatisthecauseof
variousphysicalormentalhealth
conditions ischallenged
• Disrespectful treatmentandmedical
fatshaming(inanattemptto
motivatepeopletochangetheir
behavior)isstressfulandcancause
patientstodelayhealthcareseeking
oravoidinteractingwithproviders.
People of size get the worst care
(McHugh’12;Chrisler ’07;Wolpert‘07;Ferdman‘15,Schapitl ‘18)
• Doctorsspent28%lesstime
withpatientsofsize
• Doctorsfailtorecommendfor
appropriatediagnostictests
• Delaymammograms;
gynecologicalexamsandpap
smears
• Higherdeathratebreastand
cervicalcancer
• Beingdeniedfor
reimbursementifthedoctor
referspatienttospecialist
4/26/2019
13
Woman claims doctors ignored cancer symptoms because
of her weight: 'It was very scary’
(abc ‘12)
• RebeccaHiles (28):Toldby
doctorsthatherhealth
problemswererelatedtoher
weight.
• Hiles turnedouttobesuffering
fromcancer
• Pain:Diagnosedasbeingcaused
asweightrelatedwasactually
duetoscoliosis