International Review of Psychiatry

ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: http://www.tandfonline.com/loi/iirp20

Psychosocial preventive interventions for obesity and eating disorders in youths Marian Tanofsky-Kraff To cite this article: Marian Tanofsky-Kraff (2012) Psychosocial preventive interventions for obesity and eating disorders in youths, International Review of Psychiatry, 24:3, 262-270, DOI: 10.3109/09540261.2012.676032 To link to this article: http://dx.doi.org/10.3109/09540261.2012.676032

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International Review of Psychiatry, June 2012; 24(3): 262–270

Psychosocial preventive interventions for obesity and eating disorders in youths

MARIAN TANOFSKY-KRAFF Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA

Abstract The rates of paediatric obesity have risen dramatically. Given the challenge of successful weight loss and maintenance, preventive interventions are sorely needed. Furthermore, since a substantial proportion of individuals do not respond to traditional behavioural weight loss therapy, alternative approaches are required. Psychological treatments for binge eating disorder have been generally effective at reducing binge episodes and producing weight maintenance or modest weight loss in obese adults. Given the strong link between loss of control eating and obesity in youths, binge eating disorder treatment may serve as a viable form of excess weight gain prevention. An adapted version of interpersonal psychotherapy for binge eating disorder is one such intervention that we have considered. A description of the theoretical basis and proposed mechanism is described. Adaptations of interpersonal psychotherapy and other established therapies for binge eating disorder may serve as platforms from which to develop and disseminate obesity and eating disorder prevention programs in children and adolescents.

Introduction Despite the critical problem of obesity, to date most paediatric obesity programmes have been met with limited success. Family-based therapy is considered the most effective weight management treatment for middle childhood youths (Wilfley et al., 2007). This approach involves reducing overall caloric intake as part of a comprehensive programme that includes behavioural skills (e.g. stimulus control, removing all triggering foods from the home), parenting skills, and increasing physical activity (Epstein et al., 1998). Yet, long-term weight loss following behavioural treatment remains elusive (Wilfley et al., 2007). For this reason, interventions focusing on weight maintenance, with the aim toward preventing excess gain, and targeted approaches for those individuals who do not respond to traditional methods, are urgently required to reverse the tide on the high rates of obesity.

Obesity and disordered eating In the past several years there have been numerous calls for the coordinated prevention of both obesity and disordered eating (Irving & Neumark-Sztainer, 2002; Neumark-Sztainer, 2005, 2009; Yanovski,

2003). Such efforts involve identifying potentially modifiable targets that have been demonstrated to promote both conditions. One such target is loss of control (LOC) eating. LOC eating, which often emerges in middle childhood or early adolescence, is defined as episodes of eating during which loss of control or an inability to stop is experienced, regardless of the amount of food reportedly consumed (Tanofsky-Kraff et al., 2011b). In concordance with the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition criteria, traditional interview assessments of binge eating behaviour require that a binge episode be diagnosed only if the amount of food consumed is deemed unambiguously large (Bryant-Waugh et al., 1996; Fairburn & Cooper, 1993). Yet, a substantial proportion of youths who describe experiencing LOC over eating do not report having consumed an unambiguously large amount of food. In part, it can be difficult to determine the episode size criterion for children of different ages because physically developing boys and girls have vastly varying energy needs. For example, the consumption of an entire large pizza by a child or adolescent of any age would likely be considered unambiguously large. By contrast, an amount of five slices of pizza eaten by a 16 year old boy might be less clear and thus deemed

Correspondence: Marian Tanofsky-Kraff, PhD, Uniformed Services University of the Health Sciences, Department of Medical and Clinical Psychology, 4301 Jones Bridge Road, Bethesda, MD, 20814. Tel: 301-295-1482. Fax: 301-295-3034. E-mail: [email protected] (Received 12 January 2012 ; accepted 9 March 2012 ) ISSN 0954–0261 print/ISSN 1369–1627 online © 2012 Institute of Psychiatry DOI: 10.3109/09540261.2012.676032

Targeting obesity and disordered eating an ambiguously large amount of food that, even if accompanied by a lack of control over eating, might not be classified as a binge eating episode. Furthermore, in younger children, the size of eating episodes may be limited by parental controls, masking how much a child might have eaten given the opportunity (Tanofsky-Kraff et al., 2011b). Therefore, the term LOC, as opposed to binge, is often used when working with youths; by definition, LOC episodes include classic binge episodes. Children as young as 8 years of age report LOC eating; however, it is more common in adolescence (Tanofsky-Kraff, 2008). Consistent data show that the experience of LOC during eating appears to be more salient in describing pathological eating in non-treatment-seeking children and adolescents than classic binge episodes that require the consumption of a large amount of food (Morgan et al., 2002; Shomaker et al., 2010; Tanofsky-Kraff et al., 2005). The emerging data on LOC eating suggest its prevalence ranges from 4% to 45%, with higher estimates among overweight youths (versus non-overweight), adolescents (versus pre-adolescents), and when assessed via questionnaire (versus semi-structured interview) (Tanofsky-Kraff, 2008). LOC eating appears to have genetic underpinnings (Tanofsky-Kraff et al., 2009a) and is associated with excess body weight and fat, increased disordered eating attitudes, and symptoms of depression and anxiety (Tanofsky-Kraff, 2008). Notably, LOC eating is observable in the laboratory. Children and adolescents’ reporting LOC eating consume more overall energy (Hilbert & Czaja, 2009; Hilbert et al., 2010), especially from carbohydrates such as snacks and desserts (Tanofsky-Kraff et al., 2009b). Paediatric LOC eating prospectively predicts increased weight and fat gain in middle childhood and adolescent samples (Field et al., 2003; Stice et al., 1999; Tanofsky-Kraff et al., 2006, 2009c), exacerbated adverse metabolic outcomes (Tanofsky-Kraff et al., in press), and the development of partial or full-syndrome binge eating disorder (Tanofsky-Kraff et al., 2011a). These data suggest that LOC eating is a risk factor for excessive weight gain and eating disorders in children, and may provide an important target for preventive interventions.

Loss of control eating and obesity interventions In pre-adolescent children, there are no published studies that have been designed specifically to reduce both obesity and eating disorders. Two studies examined binge eating in samples of children who underwent family-based therapy for weight loss. In brief, family-based behavioural therapy involves teaching

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parents and children about healthy eating and exercise and problem-solving skills to make healthful choices (Epstein et al., 1981). The length and number of sessions of the programme have varied across studies. In one study that involved 6 months of treatment with 16 weekly meetings, followed by two bi-weekly and then two bi-monthly meetings, Epstein and colleagues reported that disordered eating remained unchanged following treatment (Epstein et al., 2001). Wildes and colleagues, using an adapted approach (20 group meetings over 6 months with three additional meetings and three phone calls between months 6 and 12), found that the presence of binge episodes prior to treatment resulted in poorer response to family-based therapy for weight loss in the short-term (Wildes et al., 2010). In a very recent study, Boutelle and colleagues examined binge eating outcome following two alternative approaches (eight weekly sessions each) to weight management in overweight 8–12 year-olds (Boutelle et al., 2011). One treatment, involving appetite awareness, focused on identifying and monitoring hunger to increase sensitivity to hunger and satiety as well as coping skills to manage the urge to eat in the absence of hunger. The second programme used cue exposure to reduce the strength of the association between the subjective and physiological experiences when presented with food. Preliminary data suggest that treatments targeting cue exposure or appetite awareness for weight loss were both effective at reducing binge eating episodes. However, no impact on body weight was observed (Boutelle et al., 2011). Thus, there are no definitive data on whether obesity and eating disorders can be simultaneously targeted in pre-adolescent children. Further studies are needed to determine whether novel approaches to reduce both disordered eating and excessive weight gain in middle childhood may be effective. Data in adolescent samples are more promising. Two randomized, controlled trials aimed at preventing obesity in adolescents have resulted in reductions in eating disorder pathology. The first programme involved daily after school sessions for 2.5 h each that included dance classes and discussions involving the importance of dance with the aim of reducing television viewing among girls. Results indicated that participants in the experimental group trended towards greater weight loss and reported less concern about weight compared to the control group (Robinson et al., 2003). The second study, “Planet Health” (Gortmaker et al., 1999), was a two-year long schoolbased programme that included 32 core lessons (16 each year) and focused upon reducing inactivity, increasing physical activity, and augmenting healthful food consumption. The authors reported reductions in overweight among girls in the experimental group (Gortmaker et al., 1999). These girls also

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reported fewer new cases of extreme compensatory behaviours such as self-induced vomiting and laxative use (Austin et al., 2005). A third study tested the efficacy of an eating disorder intervention in preventing obesity. Stice and colleagues studied healthy weight adolescent girls who participated in two interventions designed to reduce eating disorder symptoms and attitudes compared to a control comparison and assessment only (Stice et al., 2006). Both interventions involved three 1-h group meetings that met weekly. The dissonance intervention focused on challenging attitudes regarding the “thin ideal”. The healthy weight programme focused on using healthy (as opposed to unhealthy) weight control practices. Participants who received the interventions were less likely to develop further disordered eating and become obese up to 3 years later (Stice et al., 2006, 2008). Notably, participants in the aforementioned studies were not specifically identified as being either overweight or at high-risk for excessive weight gain. Two additional studies used an Internet-based programme to simultaneously reduce obesity and disordered eating in overweight adolescents (Doyle et al., 2008). This 16-session online program combined psycho-education and behavioural interventions by incorporating cognitive behavioural therapy principles, behavioural weight loss, and hunger and satiety awareness skills. Doyle and colleagues reported few differences in either changes in body weight or disordered eating when comparing an Internet-based program to usual care 4 months following the interventions (Doyle et al., 2008). A second study reported that compared with a waiting-list control, overweight participants in the Internet-based intervention experienced reductions in LOC eating episodes, disordered eating attitudes, and BMI z-scores, through a 9-month follow-up assessment (Jones et al., 2008). Interestingly, the authors reported that the rates of adherence to the Internet intervention were low (Jones et al., 2008). Therefore, the mechanism impacting changes in body weight and disordered eating are unclear. Coupled with the absence of an active control group, results should be interpreted with caution. Nevertheless, these data are intriguing and provide preliminary support for interventions targeting both obesity and eating disorders.

Binge eating disorder treatment for paediatric obesity management Treatments for binge eating disorder may provide an important avenue towards simultaneously reducing excess weight gain and exacerbated disordered eating in growing children and adolescents (Yanovski, 2003). In general, various psychotherapies, including cognitive behaviour therapy, dialectic behaviour therapy,

and interpersonal psychotherapy, have been effective at reducing binge episodes and weight stabilization in adults. Results indicate that those who cease to binge eat tend to maintain their body weight during and following treatment (Tanofsky-Kraff et al., 2007). Since many adults with binge eating disorder report having been a healthy weight prior to binge eating on a regular basis (Fairburn et al., 2000; Mussell et al., 1995), decreasing LOC eating episodes may reduce the likelihood of excessive weight gain and prevent the onset of obesity in susceptible youths. Given the heterogeneous nature of obesity, consideration of various binge eating disorder treatments is warranted. Cognitive behaviour therapy, considered the treatment of choice for binge eating disorder (Wilson, 2011; Wilson & Shafran, 2005) and more recently proposed for weight management (Van Dorsten & Lindley, 2011), focuses upon eliminating extreme dietary restriction, increasing the variety of food intake, and decreasing cognitive distortions regarding body shape and weight. For youths with LOC eating who report extreme dieting practices (for example, fasting or periodic inappropriate compensatory behaviours), cognitive behaviour therapy may prove particularly effective. To date, there are no published studies that have used cognitive behaviour therapy to target LOC eating for the prevention of obesity or excess weight gain. Another therapy targeting emotion regulation, namely dialectical behaviour therapy, has also been effective in the treatment of binge eating disorder (Telch et al., 2001; Wilson, 2011) and might be a viable preventive approach for youths with LOC eating episodes. Similar to cognitive behaviour therapy, there are presently no data reporting the utility of dialectical behaviour therapy for the treatment of LOC eating in youths. Our group has focused on interpersonal psychotherapy (IPT). IPT was originally developed in the late 1960s by Gerald Klerman and colleagues for the treatment of depression (Klerman et al., 1984). IPT is a brief, timelimited therapy that focuses upon improving interpersonal functioning and, in turn, psychiatric symptoms, by relating symptoms to interpersonal problem areas and developing strategies for dealing with these problems (Freeman & Gil, 2004; Klerman et al., 1984). Since such time, IPT was successfully modified for adolescent depression (Mufson et al., 2004b) and for individuals with binge eating disorder (Wilfley et al., 2000). Adolescence is a developmental period during which the primary social milieu shifts from the family to the peer context (Steinberg & Morris, 2001). Since relationships and social functioning are of vital importance to adolescents (Steinberg & Morris, 2001), difficulty in these domains is likely to produce negative affect. Indeed, experiences of peer rejection in ado-

Targeting obesity and disordered eating lescence are related to social avoidance, loneliness and depression (Gazelle & Rudolph, 2004). In adolescence, social sensitivity is highly salient. Based upon both behavioural and neural imaging data, adolescents appear to be highly sensitive to social cues (McClure, 2000; McClure et al., 2004) and report concerns about peer evaluation (Rose & Rudolph, 2006). Given the vital importance of peer relationships and social functioning to adolescents (Mufson et al., 2004a), it is likely that the content addressed in IPT is appealing to youths. Notably, IPT is posited to produce its effect by reducing negative affect through improving interpersonal relationships. Thus, it is not surprising that IPT is acceptable to adolescents with depression (Moreau et al., 1991), those at risk for depression (Young et al., 2006) and is effective at decreasing negative affect and improving interpersonal and social functioning in such youths (Mufson et al., 2004b; Rossello & Bernal, 1999). IPT for binge eating disorder assumes that binge eating occurs in response to poor social functioning, such as isolation and rejection, and consequent negative moods (Wilfley et al., 1997). Since adults with binge eating disorder suffer from social impairment and poor relationships (Crow et al., 2002; Johnson et al., 2001), the proposed mechanism of IPT’s effects appear to be supported. Indeed, IPT is effective in decreasing binge episodes and inducing weight stability in overweight adults with binge eating (Wilfley et al., 1993, 2002; Wilson et al., 2010). Notably, adults with more severe psychosocial distress appear to be especially responsive to IPT (Wilson et al., 2010).

Interpersonal psychotherapy for the prevention of excess weight gain We have proposed that IPT may be suitable for overweight adolescents (Tanofsky-Kraff et al., 2007). A relatively consistent literature indicates that children with excess body weight experience frequent teasing, social isolation, and compromised interpersonal functioning (Hayden-Wade et al., 2005; Pearce et al., 2002; Strauss & Pollack, 2003). Overweight teens are teased about their appearance, stigmatized, and socially rejected (Strauss & Pollack, 2003). Not surprisingly, overweight youths experience poorer social functioning and negative feelings about themselves regarding their body shape and weight (Fallon et al., 2005; Schwimmer et al., 2003; Striegel-Moore et al., 1986). Notably, and as previously described, overweight youths with reported LOC eating appear to experience even more problems in psychosocial functioning than youths with uncomplicated obesity (Tanofsky-Kraff, 2008). Based upon this premise and data from the adolescent depression and adult

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binge eating disorder literatures, we proposed that IPT may be particularly appropriate for overweight youths with LOC eating (Tanofsky-Kraff et al., 2007). Theoretically, interpersonal problems lead to negative affect that, in turn, results in using food to cope or LOC eating, and subsequent excess weight gain (Figure 1). IPT for the prevention of excess weight gain (IPT-WG) aims at improving interpersonal functioning, which reduces negative affect, and in turn, emotional and LOC eating. The intended result should be decreased weight gain attributable to LOC eating (Figure 2). Preliminary data support the interpersonal model of LOC eating and IPT-WG. In a study of 8–17 year olds, negative affect mediated the cross-sectional relationship between social problems/interpersonal sensitivity and LOC episodes by use of structural equation modelling (Elliott et al., 2010). Moreover, based upon a pilot study of 38 adolescent girls at high risk for adult obesity by virtue of a body mass index (BMI; kg/m2) between the 75th and 97th percentiles, IPT-WG was found to be both feasible and acceptable. Compared with a standard-of-care health education programme, IPT-WG appeared to produce greater reductions in LOC eating episodes and result in less than expected BMI growth up to one year following the intervention (Tanofsky-Kraff et al., 2010). In brief, IPT-WG blends and extends upon two previously developed IPT manuals: adolescent skills training for the prevention of depression (Young et al., 2006) and Wilfley and colleagues’ adaptation of group IPT for binge eating disorder (Wilfley et al., 2000). IPT-WG is delivered in a group milieu. Similar to all modifications of IPT, IPT-WG consists of three phases: initial (providing the rationale for the approach and developing rapport among group members), middle (the work phase during which members share personal relationship experiences and role-play new ways of communication), and termination (preparing to say goodbye and for future work on goals) (Weissman et al., 2000). The manifestation of the patient’s symptoms is then conceptualized in one of four problem areas: 1) interpersonal deficits, 2) interInterpersonal problems

Negative affect

Excessive weight gain

Loss of control eating

Figure 1. Interpersonal theory of loss of control eating. Interpersonal problems cause negative affect resulting in loss of control eating and excessive weight gain.

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Reduce Interpersonal problems

Reduce negative affect Maintain weight/healthy gain

Reduce loss of control eating

Figure 2. Proposed mechanism of interpersonal psychotherapy for the prevention of excess weight gain. Interpersonal problems are decreased, thus reducing negative affect and loss of control eating. Body weight is maintained as excessive gain attributable to loss of control eating is diminished.

personal role disputes, 3) role transitions, and 4) grief. Interpersonal deficits apply to those patients who are either socially isolated or who are involved in chronically unfulfilling relationships. For patients with this problem area, unsatisfying relationships and/or inadequate social support are frequently the result of poor social skills. Interpersonal role disputes refer to conflicts with a significant other (e.g. a parent, other family member, or peer) that emerge from differences in expectations about the relationship. Role transitions include difficulties associated with a change in life status (e.g. changes in schools, graduation, moving, parental divorce). The problem area of grief is identified when the onset of the patient’s symptoms is associated with either the recent or past loss of a person or a relationship. Making use of this framework for defining one or more interpersonal problem areas, IPT focuses on identifying and changing the maladaptive interpersonal context in which the eating problem has developed and been maintained. Broadly, the focus of IPT-WG involves linking difficult relationships and negative affect to LOC eating. A pre-group session focuses on reviewing the adolescent’s current body weight and eating patterns that place him/her at high risk for excessive weight gain and adult obesity. Psycho-education about the relationship between adult obesity and impaired health, and psychological and social functioning is discussed. Throughout the course of the intervention, participants are encouraged to link their interactions and mood to their eating patterns.

Underserved minority groups In the USA, the obesity prevalence is especially high in underserved paediatric populations, with an estimated 28% of African American and 20% of Latino youths who are overweight (Ogden et al., 2006). Notably, African American and Latino youths report high rates of LOC eating, and binge eating disorder is the most common eating disorder in these groups (Swanson et al., 2011). IPT-WG may be an especially effective medium for underserved communities. Given the number of positive studies of IPT for adolescent depression in Latino samples (Mufson et al., 2004b; Rossello & Bernal, 1999; Young et al., 2006), IPT is recommended as the treatment of choice for depression among Latino adolescents (Huey & Polo, 2008). For eating disorders, data suggest that patients of ethnic/ racial minority groups tend to find IPT more acceptable for binge eating disorder (Wilson et al., 2010) and more effective for bulimia nervosa (Chui et al., 2007) than other treatments. Based on these findings, it has been suggested that IPT might be the eating disorder treatment of choice for minority groups and that other highly effective therapies may be of limited use because they are either inaccessible or aversive to these individuals (Shafran, 2010). There are several reasons why IPT may resonate with individuals, especially adolescents, of diverse races/ethnicities. IPT is personalized in nature: problem areas and goals are developed based upon each individual’s unique social environment. In essence, IPT is modifiable for, and thus may be particularly acceptable to, people of various cultures and backgrounds. In terms of obesity interventions, adolescents from different backgrounds face many culturally specific challenges to healthy eating (e.g. an emphasis on large celebratory meals) and physical activity (e.g. certain clothing or hair styles that may make it difficult to participate in exercise). IPT is well poised to address individual cultural differences because its primary focus is on the negative emotions that drive LOC eating regardless of the particular situation that generates negative affect and promotes LOC. Furthermore, IPT places a great deal of emphasis on positive family relationships. For many cultures (e.g. Latino and African American), interpersonal familial connectivity is highly valued (Hardway & Fuligni, 2006; MulvaneyDay et al., 2007; Romero et al., 2004).

Who might benefit from IPT-WG As described, adolescents who are at high risk for inappropriate weight gain and binge eating disorder by virtue of excess body weight and reports of LOC eating may be particularly appropriate candidates for IPT-WG. In addition, other special groups may benefit from IPT-WG.

Military dependents In the USA, child dependents of military personnel suffer from significant stress due to factors associated with their parents’ military careers. Youths of recently deployed personnel are at high risk for difficulties in

Targeting obesity and disordered eating psychological functioning (Jensen et al., 1996; Peebles-Kleiger & Kleiger, 1994; Rosen et al., 1993). Furthermore, parents are returning home with significant difficulties – post-traumatic stress disorder, traumatic brain injury and other physical injuries – that impact their children. Between 11 September 2001 and 2009, almost two million individuals were deployed (Manos, 2010) such that millions of children are living in active duty or reserve military households. Children of deployed parents are at risk for high stress and anxiety, as well as difficulties with their parents (Gibbs et al., 2007). In addition to increased levels of depression (Jensen et al., 1996) youths of deployed parents suffer from poorer social and emotional functioning (Chandra et al., 2010). Eating disturbances appear to be one of the most common psychiatric problems identified in this population. One study reported that 34% of military personnel and dependents reported some form of disordered eating (Waasdorp et al., 2007). This study also found that up to 21% of adolescent female dependents engaged in disordered eating, including LOC eating (Waasdorp et al., 2007). Not surprisingly, the increased prevalence of obesity among the children of military personnel (Hawthorne et al., 2004) has paralleled that observed in the civilian population (Ogden et al., 2010). Therefore, improving relationships and increasing social support with IPT-WG may help adolescent dependents cope with stressors associated with their parents’ careers. Future directions Despite promising preliminary data (Tanofsky-Kraff et al., 2010), results from an adequately powered trial are not yet available. However, the current effectiveness trial is underway. To adequately test the IPT-WG theoretical model (Figure 1) and proposed mechanism of change (Figure 2), we are administering group IPT-WG or group health education to 113 girls, 12–17 years of age, all of whom are at risk for excess weight gain based upon their BMI percentile and reports of LOC eating. We are obtaining samples for genetic analysis and examining changes in adiposity via dual-energy X-ray absorptiometry, energy intake in the laboratory, reported psychosocial functioning, and LOC episodes. To date, 50% of participants have been randomized to each IPT-WG and to health education. Girls have been similar with regard to all baseline variables and will be assessed at 6 months and 1 year following the group interventions. Interested participants are also being assessed at a 3-year follow-up visit. Outcome data will be available in 2013. Nevertheless, given the urgent problem of obesity, particularly in some underserved and special populations, IPT-WG is being considered as an alternative to traditional behavioural weight management. Indeed,

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IPT-WG may be an appropriate intervention for adolescent populations dealing with unique stressors.

Conclusion The high rates of obesity require urgent intervention. Obesity is a heterogeneous problem and since behavioural approaches are not effective for all individuals, researchers and clinicians must continue to identify the physical and psychological issues underlying imbalances in energy intake relative to expenditure. IPT-WG is only one alternative approach to reducing excessive weight gain. Other treatments for binge eating disorder, such as cognitive and dialectic behaviour therapies, may be promising options for reducing the high rates of obesity. Adapting psychosocial approaches to target not only LOC eating, but also additional aberrant eating patterns that may promote obesity such as emotional eating, eating in the absence of hunger, and other appetitive traits (Shomaker et al., 2011), should be considered. Declaration of interest: This work was funded through National Institute of Diabetes and Digestive and Kidney Diseases grant no. 1R01DK08090601A1 and Uniformed Services University of the Health Sciences grant no. R072IC. Disclaimer: The opinions and assertions expressed herein are those of the author and are not to be construed as reflecting the views of USUHS or the US Department of Defense. The author alone is responsible for the content and writing of the paper.

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