Lauren B Shomaker, PhD & Marian Tanofsky-Kraff, PhD ISIPT ... · Lauren B Shomaker, PhD & Marian...

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



• 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


100% intent-to-treat for analyses

100% intent-to-treat for analyses

TheoryImprove Interpersonal

Functioning


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


Functioning


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


Functioning


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 (%

)



Functioning


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


Consort Diagram

IPT = 55 HE = 58

113 randomized

95% completed 12 w follow-up

91% completed 12 w 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

Lauren B Shomaker, PhD & Marian Tanofsky-Kraff, PhD ISIPT ... · Lauren B Shomaker, PhD & Marian...

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