Obesity
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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

Obesity

Eating Disorders


Epidemiology of obesity
Epidemiology of Obesity

  • Definition/Prevalence

  • Medical Complications

  • Social and Psychological Consequences

Eating Disorders


Key prevalence facts
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



Epidemiology of obesity1
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


Epidemiology of obesity2
Epidemiology of Obesity

  • Social and psychological consequences

    • Social prejudice (more pronounced for women)

    • Job discrimination

    • Low self-esteem, depression, anxiety*

Eating Disorders


Epidemiology of obesity3
Epidemiology of Obesity

  • Genetics of obesity

    • Adoption studies

    • Twin studies

Eating Disorders


Energy balance model of obesity

Energy Balance Model of Obesity

Caloric Intake – Caloric Expenditure

+ (Weight Gain)

- (Weight Loss)

Eating Disorders


Energy balance conceptualization of obesity
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


Assessment of obesity
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


Medical treatments for obesity
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



Evolution of behavioral treatments for obesity
Evolution of Behavioral Treatments for Obesity

  • First Generation

  • Second Generation

  • Third Generation

Eating Disorders


Cognitive behavioral treatments for obesity
Cognitive-Behavioral Treatments for Obesity

  • Self-monitoring

  • Stimulus control

  • Goal setting

  • Reinforcement

  • Education

  • Cognitive restructuring

  • Nutritional education

  • Exercise prescriptions

  • Relapse prevention training

Eating Disorders


Limitations of behavioral treatment research
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


Improving long term weight loss
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


Bulimia nervosa

Bulimia Nervosa

Eating Disorders


Diagnostic features
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


Essential features of binge eating
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


Epidemiology of bulimia nervosa
Epidemiology of Bulimia Nervosa

  • Prevalence

    • 2.8 to 5.5% (Kendler et al, 1991)

    • 4 % (Rand & Kuldau, 1992;Whitaker et al, 1990)

Eating Disorders


Epidemiology of bulimia nervosa1
Epidemiology of Bulimia Nervosa

  • Etiology

    • Genetic factors

Eating Disorders


Stice dual pathway model
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


Risk factors for bulimia
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


Risk factors for bulimia1
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


Risk factors for bulimia2
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


Risk factors for bulimia3
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


Risk factors for bulimia4
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


Risk factors for bulimia5
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


Epidemiology of bulimia nervosa2
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


Epidemiology of bulimia nervosa3
Epidemiology of Bulimia Nervosa

  • Course

Eating Disorders


Pharmacotherapy for bulimia nervosa
Pharmacotherapy for Bulimia Nervosa

  • Tricyclic Antidepressants

Eating Disorders


Pharmacotherapy for bulimia nervosa1
Pharmacotherapy for Bulimia Nervosa

  • Tricyclic Antidepressants

  • SSRI’s

  • d-fenfluramine

Eating Disorders


Pharmacotherapy for bulimia nervosa2
Pharmacotherapy for Bulimia Nervosa

  • Tricyclic Antidepressants

  • SSRI’s

  • Fenfluramine

  • Phenelzine

Eating Disorders


Cognitive model of bulimia

Cognitive Model of Bulimia

Eating Disorders


Restraint theory herman polivy 1985
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


Types of disinhibitors
Types of Disinhibitors

  • Preload

  • Alcohol

  • Depression

  • Anxiety

  • Perceived caloric content of a food

Eating Disorders


Cognitive behavioral treatments for bulimia
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


Controlled outcome studies for bulimia
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


Agras et al 2000

Agras et al (2000)

Eating Disorders


Agras et al 2000 study overview
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


Agras et al 20000 intent to treat findings
Agras et al (20000Intent-to-Treat Findings

Eating Disorders


Moderators of treatment outcome
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


Binge eating disorder
Binge Eating Disorder

Eating Disorders


Diagnostic features of binge eating disorder
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


Epidemiology of binge eating disorder
Epidemiology of Binge Eating Disorder

  • Prevalence

Eating Disorders


Associated features of binge eating disorder
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



Procedural components of cbt for binge eating disorder
Procedural Components of CBT for Binge Eating Disorder

  • Treatment rationale

  • Self-monitoring

  • Altering patients’ meal consumption

  • Relapse prevention training

Eating Disorders


Controlled outcome studies for binge eating disorder
Controlled Outcome Studies for Binge Eating Disorder

  • Telch et al (1990)

  • Wifley et al (1993)

  • Agras et al (1994)

Eating Disorders


C telch et al 1990
C.Telch et al (1990)

Eating Disorders


Wifley et al 1993
Wifley et al (1993)

Eating Disorders


Agras et al 1993
Agras et al (1993)

Eating Disorders


Procedural components of cbt for binge eating disorder1
Procedural Components of CBT for Binge Eating Disorder

  • Rationale, Overview or Treatment, Commitment Component to attend treatmentAbstinence

  • Chain analysis of binge episode (Antecedents and consequences of binge and how repair)

  • Diary Cards: Mood and binge episodes, other side skills used

  • Reviewing homework

  • Didactic/experiential component

Eating Disorders


Dbt treatment of binge eating disorder
DBT Treatment of Binge Eating Disorder

  • DBT Skill Training Areas

    • Breathing

    • Mindfulness skills

    • Emotion regulation skills module

    • Distress tolerance skills

Eating Disorders