lauren b shomaker, phd & marian tanofsky-kraff, phd isipt ... · lauren b shomaker, phd &...
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IPT for Prevention of Eating Disorders
and Excess Weight Gain in Adolescent Girls
!Lauren B Shomaker, PhD & Marian Tanofsky-Kraff, PhD
!ISIPT June 2015
Objective binge eating Subjective binge eating
Loss of Control (LOC) Eating
- Key symptom binge eating disorder (BED) & bulimia nervosa
Decaluwe & Braet, 2003, Int J Eat Disord; Goossens et al, 2007, Beh Res Ther; Tanofsky-Kraff, Han et al, 2009, Am J Clin Nutr; Tanofsky-Kraff et al, 2004, J Consult Clin Psychol
LOC Eating in Childhood
• Associated with - difficulties in social
functioning - anxiety symptoms - disordered eating attitudes
& behaviors
• More common in overweight youth
Youth with LOC display distinct eating phenotype
177 boys and girls (8-17y): Interview of LOC eating
Normal meal instruction: “Eat as much as you would
at a normal meal”
Binge meal instruction: “Let yourself go and eat as
much as you want”
Two test meals on separate days Randomized to:
Youth with LOC report greater anxiety after eating
LOC = 50 No LOC = 1270
10
20
30
40
Spielberger State Anxiety Scale
p = .01
Adj
uste
d P
ost-
Mea
l Sta
te A
nxie
ty
Adjusted for fat-free mass, % fat mass, sex, age, race, total energy intake, pre-meal anxiety Tanofsky-Kraff et al, 2009, Am J Clin Nutr
Youth with LOC consume more dessert & less lunch foods
0
100
200
300
400
500LOCNo LOC
DairyDesserts& Snacks
Meats Vegetables Fruits
p = .05
p = .04
p = .02
Ad
just
ed k
cal
Tanofsky-Kraff et al, 2009, Am J Clin NutrAdjusted for fat-free mass, % fat mass, total energy intake, sex, age, and race
Overweight girls with LOC consume more at a “binge” meal
Normal Meal Binge Meal1000
1250
1500
1750LOC = 22No LOC = 23 p = .03
Adju
sted
Ene
rgy
Inta
ke (k
cal)
Adjusted for fat-free mass, % fat mass, sex, age, and race Tanofsky-Kraff et al, 2009, Am J Clin Nutr
Who would you like to chat with?
fMRI social stress task highlights role of anxiety
Immediately following: “Let yourself go and eat as much as you
want”
…
They are….
…interested …not interested
Scanner
Selected Rejected
Negative peer feedback elicited diminished engagement in ventromedial prefrontal cortex* in girls with LOC
LOC Status x Peer Feedback F = 35.51; p < .005; ke = 41*Interpreting social intentions
Self-reflection
Affect modulation
Jarcho, Tanofsky-Kraff et al, 2014, Neuroimage
LOC No LOC-0.2
-0.1
0.0
0.1
0.2
n=10 n=12%
Sig
nal C
hang
e
Bilateral fusiform face area* activity positively associated with energy intake in LOC girls
LOC x Peer Feedback x Peer Interest x Intake Right: F = 19.22; p < .005; ke = 13
Left: F = 24.93; p < .005; ke = 15
Jarcho, Tanofsky-Kraff et al, 2014, Neuroimage
*Face perception Decipher social intentions Enriched processing of emotionally salient objects
-0.6 -0.4 -0.2 0.0 0.2 0.40
1000
2000
3000
4000
No LOCLOC
Difference in % Signal Changein Peer Feedback
Tota
l Int
ake
(kca
l)
LOC PREDICTS BOTH BED & EXCESS WEIGHT GAIN
These anxiety-eating patterns may offer some preliminary explanation for why
0
5
10
15
No LOCat baseline
LOC Everat baseline
Follo
w-u
p pa
rtia
l/ful
lbi
nge
eatin
g di
sord
er (%
) LOC >10x more
likely to develop
diagnosis
p = .03
Tanofsky-Kraff et al., 2011, J Abnorm Psychol
LOC predicts development of BED
LOC predicts excessiveweight gain over time
LOC No LOC0.0
0.5
1.0
1.5
2.0
p = .02
n = 19 n = 124
Adj
uste
d M
ean
BMI g
ain/
y
Tanofsky-Kraff et al., 2009, Int J Eat Disord
Youth with LOC gained
2.5 kg/5.3 lbs more per
year
LOC may be target for preventing BED & excess weight gain
LOC Eating
BED & Excess Weight Gain
Red
uce
Red
uce
Rationale for IPT Approach• In adults with BED and obesity, IPT - reduces binge episodes
- results in weight maintenance in individuals who no longer binge eat
- IPT resonates with teens at-risk for depression and with major depressive disorder
1993, J Consult Clin Psychol; 2002, Arch Gen Psychiatry; 2010, Arch Gen Psychiatry
Grounded in Interpersonal Theory of LOC
Tanofsky-Kraff et al., 2007, Obesity
Improve Interpersonal Functioning
Decrease Negative Affect
Reduce LOC Eating
Prevent BED/ Excess
Weight Gain
Interpersonal Problems
Trigger Negative Affect
LOC Eating
BED/ Excess
Weight Gain
Research Objective
Test if IPT-WG is more effective than control for reducing LOC eating and preventing excess weight gain in adolescent girls at
high-risk for excess weight gain
Hypotheses
Compared to control group, girls who participate in IPT-WG will be less likely to:
– report the presence of LOC episodes – increase BMI
…over 1 year follow-up …at longer-term 3 year follow-up
Participants
Inclusion - Females 12 - 17 years - BMI: 75th - 97th percentile - Report of >1 recent LOC episode
!Exclusion - Major medical or psychiatric problem - Recent weight loss > 3% - Beck Depression Inventory (BDI)-II score > 25
Overview of Study Design
Baseline
• Depressive symptoms • Anxiety symptoms • LOC • BMI metrics !
IPT-
WG
or H
E
12-Week Post-Tx Follow-up
6-Month Follow-up
3-Year Follow-up
1-Year Follow-up
• Depressive sx • Anxiety • LOC • BMI
• Depressive sx • Anxiety • LOC • BMI
• Depressive sx • Anxiety • LOC • BMI
• LOC • Depressive sx • Anxiety • BMI
IPT-WG: IPT for Prevention Excess Weight Gain
• Selective prevention program: at-risk for BED & excess weight gain
• Co-facilitators • 1 90-min individual pre-group
meeting • 12 90-min group sessions • Explicit linking
relationships-affect-eating
• Mid- & post-group individual check-ins
• Draws on IPT-AST (Young) & IPT for eating disorders (Wilfley)
Consort Diagram
166 (20%) screening visit
IPT = 55 HE = 58
113 randomized
830 responded to ads
Baseline CharacteristicsIPT
n = 55Health Ed
n = 58!
pAge (y) 14.2 ± 1.5 14.8 ± 1.7 .05
Pubertal breast stage (1-5) 4.2 ± 1.1 4.3 ± 1.0 .59
Race/ethnicity (%) • Non-Hispanic White • Non-Hispanic Black • Hispanic/Other
!52 26 32
!62 22 16
.84
BMI (kg/m 26.9 ± 2.6 27.1 ± 2.4 .63
BMI percentile 92.4 ± 4.6 92.1 ± 4.8 .79
LOC eating (%) 100 100 --
Objective binge eating (%) 26 38 .20
Consort Diagram
IPT = 55 HE = 58
113 randomized
95% completed 12 w follow-up
91% completed 12 w Follow-up
89% completed 1 y follow-up
84% completed 1 y follow-up
100% intent-to-treat for analyses
100% intent-to-treat for analyses
TheoryImprove Interpersonal
Functioning
Decrease Negative Affect
Reduce LOC Eating
Prevent BED/ Excess
Weight Gain
No change in social functioning in either group
Baseline Post-Group 6-Month 12-Month2.0
2.2
2.4
2.6
2.8 IPT-WGHealth Ed
Interval
Soci
al A
djus
tmen
t Pro
blem
s
Tanofsky-Kraff et al, Am J Clin Nutr, 2014
TheoryImprove Interpersonal
Functioning
Decrease Negative Affect
Reduce LOC Eating
Prevent BED/ Excess
Weight Gain
Improvements in anxiety symptomsin both groups
p = .03
Baseline Post-Group 6-Month 12-Month29
31
33
35
37IPT-WGHealth Ed
Interval
Anxi
ety
Sym
ptom
s
Interval p < 0.001 Tanofsky-Kraff et al, Am J Clin Nutr, 2014
Improvements in depression in both groups
p < .001 p < .001
Baseline Post-Group 6-Month 12-Month
4
6
8
10
12
14
IPT-WGHealth Ed
Interval
Depr
essi
ve S
ympt
oms
Interval p < 0.001Tanofsky-Kraff et al, Am J Clin Nutr, 2014
TheoryImprove Interpersonal
Functioning
Decrease Negative Affect
Reduce LOC Eating
Prevent BED/ Excess
Weight Gain
Both groups reduced LOC eating
during the programs and by 1 y
0
20
40
60
80
100
IPT-WG Health Ed12 wk 1 yBaseline 12 wkBaseline 1 y
LOC
eat
ing
pres
ence
(%)
p < .001
p = .001
p < .001
p = .001
Tanofsky-Kraff et al., 2014, Am J Clin Nutr
Presence of objective binge eating lower in IPT at 1 y
0
10
20
30
40
IPT-WG Health Ed
p = .01
12 wk 1 yBaseline 12 wkBaseline 1 y
Bin
ge e
atin
g pr
esen
ce (%
)
Tanofsky-Kraff et al., 2014, Am J Clin Nutr
TheoryImprove Interpersonal
Functioning
Decrease Negative Affect
Reduce LOC Eating
Prevent BED/ Excess
Weight Gain
Girls in Health Ed may be more likely to develop eating disorder at 1 year
IPT-WG Health Ed0
2
4
6
8
10
p = 0.20, 95% CI .46, 39.6
Eatin
g D
isor
der a
t 1 y
(%)
Girls in Health Ed >4x more likely to develop eating
disorder
1 anorexia nervosa-type 3 bulimia nervosa-type
1 anorexia nervosa-type
Tanofsky-Kraff et al, Am J Clin Nutr, 2014
Both groups reduced BMI z
1.2
1.3
1.4
1.5
1.6
1.7
IPT-WG Health Ed
12 wk 1 yBaseline 12 wkBaseline 1 y
BM
Iz
p = .02 p = .02
Tanofsky-Kraff et al., 2014, Am J Clin Nutr
Consort Diagram
IPT = 55 HE = 58
113 randomized
95% completed 12 w follow-up
91% completed 12 w Follow-up
89% completed 1 y follow-up
84% completed 1 y follow-up
54% completed 3 y follow-up
58% completed 3 y follow-up
LOC (nor binge) presence at 3 y does not differ
IPT-WG Health Ed0
10
20
30
40
50
3 y
% L
OC
Pres
ence
p = .19
n = 1 with BED
Girls with baseline high anxiety in IPT-WG have least BMI gain 3 y later
Baseline Low Anxiety Baseline High Anxiety-2
-1
0
1
2
3
3 y
Chan
ge in
BM
I (kg
/m2)
IPT-WGHealth Ed
p=0.04
Adjusted for baseline BMI, LOC, age, race, cohort, attendance, time to 3-y follow-up
Summary
• IPT-WG modestly more efficacious than Health Ed – reduced binge eating 1 year later – reduced BMI gain in those with high baseline anxiety
3 years later • Next step to consider targeting youth based on
even more specific endophenotypes – Neural, stress, laboratory feeding models support
links between LOC and anxiety
Strengths and LimitationsStrengths • Theoretically-driven • Use of a comparison group matched for time and attention • Ethnically/racially diverse sample • High retention at 1 year follow-up !Limitations • Considerable attrition at 3 year follow-up • Impact of observed improvements in negative affect, LOC
eating, and BMI is unclear
CURRENT AND FUTURE DIRECTIONS
IPT-WG
IPT-WG in Military Families
• Overweight impacts the military family • Share similarities with civilian counterparts, but
face unique challenges (e.g., stress related to deployments and relocations)
• LOC and disordered eating more exacerbated in teens from military (v. civilian) families
Schvey et al., 2015, Int J Eat Disord; Tanofsky-Kraff et al., 2013, Obesity
Ongoing pilot study and larger trial to test IPT-WG in teens of military families
Decreases in Depression and Anxiety in IPT-WG
Baseline Post-Treatment0
5
10
15
20
Dep
ress
ive
Sym
ptom
s IPT-WGHealth Ed
p = .02
p = .14
Baseline Post-Treatment10
15
20
25
Anx
iety
Sym
ptom
s IPT-WGHealth Ed
p = .01
p = .19
IPT-WG tends to produce greater reductions in LOC than Health Ed
0
25
50
75
100
LOC
(%Pr
esen
t)IPT-WGHealth Ed
Baseline BaselinePost-Tx Post-Tx
100%
100%
100%
75%
33%
p = .09
IPT-WG in Teen Pregnancy
• Prevention of excess gestational weight gain
• Based on same interpersonal model, as applied to disinhibited eating in teen pregnancy
Acknowledgments
!National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health,
1R01DK080906 !
Center Project Program, Uniformed Services University of the Health Sciences, 72NC
Acknowledgments
• Cara Olsen, DrPH • Tracy Sbrocco, PhD • Mark Stephens, MD • Denise Wilfley, PhD • Jami Young, PhD • Jack A. Yanovski, MD, PhD
Statistical Plan
1-year outcomes• Binary logistic regression
– DV—LOC presence (1y)
• General linear models with repeated measures – DV—BMI
• Covariates baseline height & age
3-year outcomes• Binary logistic regression
– DV—LOC presence (3y) • General linear models
– DV—BMI • Baseline depression &
anxiety as moderators • Covariates baseline DV,
age, race, cohort, attendance, & time to follow-up
- FIML or MI to handle missing data