Yale Psychiatry Grand Rounds: January 7, 2022

January 07, 2022

"Developments and Recent Advances in Treatment of Binge Eating Disorder and Obesity"

Carlos M. Grilo, PhD, Professor of Psychiatry and of Psychology, Yale School of Medicine

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00:00Thank you very much, I appreciate it.
00:03Very much the opportunity to
00:06speak to folks about our work,
00:08and I certainly appreciate everyone here.
00:14Making the time to join us this morning
00:18to hear about some of our work.
00:21Again, I will provide an overview,
00:24a balanced overview of
00:27developments in recent advances.
00:29Regarding binge eating disorder
00:32and its treatment. I will try.
00:36To be balanced along side that I
00:39will also try to highlight a lot
00:43of the work that our program here
00:45at Yale has been working hard on.
00:50The usual disclosures in past 24
00:53months I've received royalties for
00:56academic books from Guilford Press
00:58and Taylor and Francis Publishers.
01:00Our aims are to look at the prevalence of BD,
01:06its distribution and associated
01:08comorbidities,
01:09talk a little bit about the
01:10diagnosis of being D,
01:11its clinical features,
01:13and associated context that's relevant.
01:15For case and clinical formulation.
01:17Provide an overview of the
01:21evidence base for psychological and
01:24pharmacological interventions for DD.
01:26And then focus a bit more on the recent
01:28advances in effective treatments for being D.
01:30As long as we, as,
01:31along with recent advances in
01:34methods for trying to gain a
01:37better understanding of which
01:39treatments work and for whom they
01:42may work and ways to enhance them.
01:46PD was included for the first time
01:49as a research diagnosis in the DSM 4.
01:52And then following a fair amount of research,
01:55it was bumped up to a
01:57formal category in the DSM.
01:585 criteria are listed here.
02:02The main piece that pay that's
02:05really focused on perhaps too much.
02:07I'll say a little bit about that a
02:09little while with binge eating episodes.
02:11This is a two part definition.
02:13It's eating unusually large
02:15quantities of food and I believe,
02:19and I believe the empirical literature
02:21suggests that the subjective sense of
02:23loss of control that needs to accompany
02:25it is actually the key feature.
02:26In fact, the ICD has eliminated the need
02:30for unusually large quantities of food,
02:32and they focus more on a
02:33subjective sense of control during.
02:34Certain eating episodes,
02:36but here on this side up on the
02:39diagnosis requires large quantities
02:41of food while experiencing a
02:43subjective sense of loss of control.
02:45Loss of control can be a
02:48little vague for some people.
02:50If you capture it as a
02:51clinician and talking to them,
02:53you'll see the light bulb go off.
02:55If not,
02:55you sometimes have to guide them
02:57through it because they haven't
02:58talked about this with other people
03:00with the SM provides us with five
03:03behavioral indicators for assessing
03:04the loss of control and diagnosis.
03:06Requires endorsement of at
03:07least three of these.
03:08These include things such as
03:10eating much more rapidly than
03:11usual during that episode,
03:13eating large quantities of
03:14food despite not being hungry,
03:16eating until physically and
03:18emotionally uncomfortable or painful.
03:20Eating alone due to embarrassment about the
03:22quantity or the nature of the eating itself,
03:25and then feeling disgusted,
03:27guilty, and depressed afterwards.
03:28Those are strong words.
03:29This is not the regret of having overeaten.
03:32These are really intense emotional sequelae.
03:35The diagnosis requires that there be
03:37market distress about binge eating.
03:39Interestingly, some people do.
03:44Experience.
03:46With those behavioral features
03:47and the loss of control,
03:49and are not particularly distressed about it.
03:51The DSM would exclude those
03:55people from the diagnosis.
03:58The couple of exclusionary features.
04:01There are no wait,
04:02compensatory behaviors such as
04:04the extreme restriction that
04:05characterizes anorexia nervosa,
04:07and there is the absence of a
04:11variety of inappropriate purging
04:13behaviors that characterize bleeding.
04:16There no Rosa,
04:17the frequency is requirements and
04:20stipulations are that at least one
04:23loss of control episode happened weekly
04:26with the duration of at least three months.
04:29This is a self monitoring record to
04:31give you a quick idea from a clinical
04:34perspective of what the eating
04:36architecture topography may look like.
04:39And it's not just so much the eating.
04:41It's not so much the healthiness
04:43and sometimes different eating
04:44episodes can look rather similar.
04:46It's when the loss of control
04:48kicks in that we can categorize the
04:50presence of a binge eating episode.
04:53So this gentleman starts off
04:54today at 7:00 o'clock,
04:56through a drive-thru as a
04:58toasted bagel with egg, sausage,
04:59and cheese, a coffee roll,
05:01large regular coffee.
05:04Not a great nutritional start to the day,
05:06but. Didn't concern this gentleman.
05:13At 12:00 o'clock, another fast food
05:15restaurant to beef burritos at beef,
05:17a bean burrito and extra large soda goes
05:19back to the office for Chocolate Chip
05:22cookies and Work Lounge with his coworkers.
05:24Gentleman arrives home and
05:27he lives alone about 6:15.
05:30Start thinking about ordering dinner,
05:32ordering a pizza.
05:34He proceeds as some chip dip and pretzels.
05:38A few minutes later has
05:39some crackers with cheese.
05:40Has a half a bowl, leftover macaroni
05:42while watching television awaits.
05:43Green pizza, delivery,
05:45pizza delivery finally comes on.
05:47The gentleman has four
05:48slices of sausage pizza,
05:50a bag of chips and two sodas that's
05:53experienced by him as his dinner.
05:56Again, not a stellar nutritional.
05:59Day, but you do see a bit of structure to
06:02the day and that it's not continuous eating
06:05like we sometimes see in some of these folks,
06:08there are some eating episodes that are
06:11roughly at mealtimes and so on and so forth.
06:14An hour and a half later,
06:15despite being.
06:17Completely satiated.
06:20Gentlemen,
06:21thinking about some things against the field,
06:24some distress goes back into the kitchen.
06:26And proceeds to have another 4 slices of
06:29the sausage pizza and finds bowl with the
06:32leftover macaroni and cheese finishes.
06:34It grabs 3 or 4 handfuls of chips
06:37and reported literally stuffing
06:40them in his mouth and then had a
06:43leftover sandwich that was tucked
06:45away on the side of the refrigerator.
06:48During this episode he labeled
06:50it as a binge eating episode.
06:52He said he was eating.
06:53He didn't know why he was eating.
06:54He was eating rapidly.
06:55He was.
06:56Shoving the food in his mouth.
06:58It was actually uncomfortable and he
07:01felt utterly disgusted with himself.
07:03If you look at the binge in the dinner,
07:05just not really much of a difference there,
07:07it is really the subjective
07:09experience during the latter,
07:10so this is not an issue around
07:13overeating which most of us do
07:15from time to time or frequently,
07:17but rather a an episode that is very
07:20salient and individuals who experience
07:23these episodes are quite distressed by them.
07:27How common is this?
07:30Our colleagues and I.
07:33Performed a epidemiologic analysis.
07:38With this arc three which use DSM 5.
07:43Criteria and we found that BD is
07:45more prevalent than either anorexia
07:47nervosa or bulimia nervosa.
07:49Our estimate was a lifetime rate of .85%.
07:53This rate is lower than previous studies.
07:56This rate, however,
07:58is consistent with the median
08:00rates performed with a variety
08:02of large scale European.
08:04Studies.
08:05Interestingly,
08:06and importantly,
08:08understanding the the distribution
08:10is valuable for clinicians to help
08:13recognize what potentially recognize
08:15this problem occurs in men and women.
08:18More women than men appear to
08:20suffer from binge eating disorder,
08:22but it does not show the market
08:24gender distribution that we
08:26see for anorexia nervosa.
08:27In particular,
08:28a BD occurs across ethnic and racial groups.
08:31People of color appear to have
08:35strikingly comparable rates.
08:37As as wide as individuals,
08:40BD occurs across all weight groups,
08:43but is associated strongly with severe
08:45obesity that we have a treatment confound
08:47in the sense that in most clinical settings
08:50most people with PD have coexisting obesity,
08:54but at the national community level
08:56it is found across all week groups.
08:58But if you wait long enough, the excess
09:01weight will eventually build the association.
09:03With obesity is a strong one.
09:06Large ratios there from three of the
09:08major epidemiologic studies and National
09:10comorbidity survey replication at a 4.9.
09:14Odds ratio adjusted odds ratio.
09:16The World Health Organization Mental
09:18Health Study 6.6 and our analysis
09:20with Nice start three point 4.6 again.
09:24I emphasize that obesity and weight
09:26fluctuation are most often the reasons
09:28that lead people to seek treatment,
09:30not to be D itself.
09:33It is associated with elevated
09:36risk psychiatric occurrences.
09:37Nationally,
09:38representative samples consistently find
09:39that the majority in the vast majority,
09:42nearly all patients have at least
09:44one other psychiatric disorder.
09:46The most common Co occurring disorders
09:48are listed there in our in our analysis,
09:5170% moved 68% Sud and 59% anxiety disorders.
09:58These rates are fairly comparable
10:00to other large scale studies.
10:03This is sometimes viewed as are
10:07the other eating disorders.
10:08Unfortunately, as you know,
10:10using unfortunate term as boutique disorders,
10:12these disorders are associated with
10:15high rates of chronicity and rather
10:18concerning functional impairments.
10:20Just as one example,
10:22you're the prevalence rates that
10:25we found for persons with eating
10:28disorders and the adjusted odds ratios
10:30for suicide attempts in persons
10:33with binge eating disorder was 4.8.
10:35Three,
10:36that's a fairly concerning elevation
10:40and risk of interest,
10:42and the reasons are uncertain.
10:44The onset of BD was significantly
10:45more likely to proceed.
10:47Suicide attempts in those
10:48persons characterized with BD,
10:50whereas people characterize,
10:52without erexion impulsive blooming orvos,
10:54it was about half and half.
10:56Point being there are significant social,
11:01psychosocial,
11:02and functional impairments as well
11:04as other kind of important health
11:06indicators that these individuals
11:08suffer from.
11:09In terms of medical Co,
11:11occurrences also has high elevated,
11:14significantly elevated risk for a
11:16variety of medical Cohen currencies.
11:19First and foremost, obesity,
11:21which I mentioned earlier,
11:23but a variety of cardio,
11:24metabolic problems,
11:25various Crain,
11:26chronic pain conditions and elevated
11:29rates for a variety of these
11:31medical conditions are elevated
11:33even after adjusting for a variety
11:35of socio demographic factors as
11:37well As for adjustment for obesity.
11:39The World Health Organization study
11:42also found that the significant
11:44associations were temporarily
11:46primary be deleting or proceeding
11:49subsequent medical comorbidities.
11:51Something that does not come up
11:53in the DSM or in a lot of kind of
11:57clinical settings is a critically
11:59important context that I would like
12:02to highlight and that is the issue of
12:05weight based stigma and negative biases.
12:08To put it bluntly,
12:10negative weight based stereotypes in
12:12our society and similar societies
12:14offer basic individuals with obesity
12:17are widely viewed as lazy and lacking
12:19in self discipline and in rural power.
12:22Tests and and assessments
12:25asking for explicit.
12:27Views document this. Remarkably.
12:33Stigmatising view that many of us
12:36have studies that look at implicit
12:40ways of getting at these attitudes.
12:42Find the same.
12:43I emphasize that such views exist
12:45even among health care workers and
12:47studies have also done documented
12:50that these views are often common,
12:52often present even in health care
12:55workers with a specialty in the areas of
12:58obesity and related metabolic problems.
13:00So that's one problem.
13:02The second problem is that such
13:04views are often internalized
13:06by the patients themselves.
13:07Unlike some other discrimination
13:10and stigmatizing experiences,
13:11people with obesity often
13:13buy into the same views,
13:14and they begin to stigmatise themselves with
13:18the same harsh language and harsh views.
13:21So persons with obesity face.
13:26Would be The Who have coexisting obesity and
13:29come to us for help face weight based stigma.
13:31They have long histories of being stigmatized
13:34because of their size and their weight,
13:36and they also have the added
13:38shame about the binge eating.
13:40So it's a kind of a double whammy,
13:41so appreciation of the history.
13:44There are many of our patients have with
13:46weight based bias and discrimination
13:48experiences is essential for effective care.
13:51Language matters a great deal.
13:53To belabor this point further,
13:54this is an example.
13:55This is not just bad manners.
13:57This is not just we need
13:59to be more respectful,
14:00which I think we do.
14:02This has medical consequences,
14:04so just as an example analysis we
14:07did with Denise Arc wave one and two,
14:09we looked at weight based discrimination,
14:11race based discrimination and sex
14:13based discrimination and wave one and
14:16associations with new cardiovascular
14:21reports or incidents that we too.
14:24Even after adjusting for
14:26sociodemographic factors,
14:27adjusting for BMI, adjusting for smoking,
14:30alcohol, depression and stress,
14:32we found that weight and race
14:35based discrimination experiences
14:37were associated with elevated odds
14:40ratios for new cardiovascular.
14:43Disease reports
14:46adults who perceive weight
14:48and racial discrimination and
14:49multiple forms of discrimination.
14:51The previous slide did not show the analysis.
14:53We actually looked at the impacts of
14:55multiple forms of discrimination may be
14:57at heightened risk for certain types
14:59of disease and with chronic medical
15:01conditions among persons with obesity.
15:03Clinically, we are starting
15:04to see that stigma,
15:05internalized weight biases are
15:07associated with poor weight outcomes
15:10and with reduced preventative care.
15:12Many clinicians talk about poor
15:14follow up and everything else.
15:16A lot of patients when we interview
15:18them and assess them overtime,
15:20they often attribute the limited
15:23follow-up to unfortunate and
15:25stigmatising experiences.
15:28Another aspect of binge eating disorder
15:30that I wish to highlight and this,
15:31I think is a major diagnostic
15:34shortcoming in the DSM is the absence
15:37of a body image criterion for BD body.
15:41Image criteria are front Center for
15:44Nexium and for bulimia nervosa.
15:47We know that body image concerns are
15:50much stronger in persons with BD than
15:53in persons with obesity without BD.
15:55Overvaluation of shape and weight
15:58which is indistinct.
16:00Construct this is not being unsatisfied
16:02with one's weight and shape,
16:03which in Western cultures is
16:05merely normative. If you will.
16:07This is a cognitive process by which
16:11people defined define their primary
16:13worth as a human being based on their
16:16ability to control their weight or
16:18shape or what their weight and shape
16:20is viewed as and for whatever reason.
16:23It was not a diagnostic criterion
16:26or specifier for BDE to DSM 5.
16:28A series of our studies in clinical.
16:31Community convenience sample that
16:34epidemiologic samples demonstrated
16:36overvaluation was associated with
16:38greater severity in a variety
16:41of these adult samples.
16:43We have done predictor analysis with
16:45a variety of trials and we found
16:48that its overvaluation is associated
16:50with poor treatment outcomes.
16:52The figure to the bottom there shows
16:56rather a significant difference at
16:58follow up between patients who had
17:01overvaluation and higher levels
17:03of valuation at baseline,
17:05so it predicts poor outcomes.
17:08It predicts and is associated with
17:10poor functioning and variety of ways.
17:12I feel it should be.
17:13Diagnostic specifier or criterion.
17:15But regardless of that,
17:17in your case formulation,
17:19it is an important thing to assess
17:22and to understand very few moderators
17:24of treatment have been identified
17:26in the first study there that
17:31JC P222 2012 paper we actually
17:33found a very useful moderator
17:35effect in that if you had
17:37people high in overvaluation,
17:39they did better in CBT,
17:42and if you gave them
17:44pharmacotherapy without CBT,
17:46they did. Rather miserably
17:51so let me belabor this a little bit further.
17:56Then that that that kind of crawling
17:59through the importance of overvaluation,
18:01comes from our traditional
18:03models of psychopathology.
18:05A little bit about a complementary
18:07approach which involves network analysis.
18:09Uhm? Again, our traditional models
18:12view symptoms as somehow emerging
18:14from some sort of underlying entity.
18:16If you, if you will network models,
18:19you disorders and ever in
18:21a in a very different way.
18:23That there are these symptoms,
18:25they're interconnected.
18:27They influence one another.
18:28They are maintained by one another
18:30and they interact with one another.
18:32If we are able to find ways to quantify.
18:38The symptom interactions.
18:41Within, you know some sort
18:43of hypothetical construct.
18:45We can then identify the
18:46symptoms that are most central.
18:48Again, the most central
18:50being the key lingo there.
18:52And the way that this is manifested
18:54on the on the left side on
18:55the blue you have the circles.
18:57Those are symptoms.
19:00Symptoms.
19:02The lingo in in in that field is nodes and
19:06then you have the various lines you see all
19:09sorts of lines between all the symptoms.
19:11The lines are called edges. In that system,
19:13the thicker the edges the the stronger.
19:18Interactions and and the connections.
19:20So the most central symptoms in the
19:22network are those that caused most
19:25others or internal caused by most others.
19:28If you look on the right,
19:30the red you can see the rank ordering of
19:33the centrality and overvaluation of shaping
19:35and weight are the core symptoms of the.
19:39So that's another.
19:41Reason I think that overvaluation of
19:44weight and shape is an important aspect.
19:47So in terms of treatment needs is
19:49a complicated construct and binge
19:51eating behaviors. The disordered,
19:52unhealthy eating outside the binge,
19:54eating associated cognitive features,
19:56the obesity, the medical comorbidities,
19:59psychiatric comorbidity,
20:00body image, in particular,
20:01valuation of shape and weight and larger,
20:04broader structural context that obesity,
20:07stigma and discrimination experiences.
20:13Well, a lot of people with BDC treatment
20:16but they don't seek treatment for BDD.
20:19Here when we looked at this and niece
20:21are less than half people reported
20:24every seeking treatment for BD.
20:26When they do seek treat on that,
20:28by the way, is particularly striking
20:30for men and for people of color.
20:33When they do seek treatments for other
20:34things and when they are in treatment
20:37for whether it's medical comorbidities
20:38or psychiatric comorbidities,
20:40they are rarely asked about their
20:42binge eating. They're often.
20:46Counseled or told or criticized for their
20:50eating behaviors and their weight, perhaps,
20:52but they're never asked about their body.
20:55Image concerns and never asked about
20:57any kind of binge eating patterns.
20:59This large scale survey with over 20,000 US
21:04adults found that of those with PD diagnosis.
21:07Only three point.
21:092% of them had been diagnosed by
21:13any of their health care providers.
21:16So it goes unrecognized.
21:17Good news is this is something if
21:20we can recognize that there are a
21:22variety of treatment options available.
21:24Start with pharmacol therapy.
21:27Small RCT's have found that a variety
21:30of medications are superior to placebo.
21:32Food duesing binge eating,
21:33at least over the short term.
21:35The effects from an effect size perspective
21:38are not particularly oppressive.
21:40Except for topiramate.
21:43Agents at the epileptic agent,
21:45which reduces both binge eating
21:46and weight over the short term.
21:48Most of the medications taste tested to date,
21:50have yielded minimal losses.
21:53Sadly,
21:53there's only one FDA approved
21:56medication for BED.
21:57Currently that's listex feta
21:59mean it's a prodrug stimulant.
22:01Those of you who work with
22:03ADHD know that as Vyvanse,
22:05this is the only FDA approved
22:07medication for BD.
22:08By the way,
22:09there are no FDA approved medications
22:11for anorexia nervosa and ferocity is
22:13the only FDA approved medication for
22:16bulimia nervosa going to present some
22:18emerging findings for various medications.
22:20And I should note that there's almost
22:22no data existing regarding the longer
22:24term effects of pharmacotherapy
22:25and not lead up to some of the
22:27studies that we're doing at power.
22:28Now to try to address that,
22:30the available studies,
22:31mostly hours,
22:32have found that seeking to be a
22:35superior to medications over the long haul.
22:37These are the.
22:38This is the summary slide of
22:41pivotal findings from the trials
22:43from from this text that feta
22:45mean that led to the FDA approval.
22:48LDX at dosing of 50 to 70
22:52milligrams over 12 week period.
22:54Separated significantly from
22:56placebo with pretty good effect.
22:58Sizes .83 and higher.
23:02And if you look at categorical remission,
23:04rates are complete.
23:06Abstinence from binge eating.
23:08The remission rates were 36% and
23:1140% versus 13% and 14% for placebo.
23:19We also did a study out,
23:21collaborated on study with Destro Lean.
23:24This is a DNR inhibitor.
23:27The design of the study was
23:29almost identical to the LVX.
23:33Pivotal studies one was a flexible dose
23:38and it was superior to placebo for
23:41reducing binge eating or remission.
23:43Rate was 47% versus 21%.
23:47A fixed dose follow-up study
23:49found that 6 milligrams but not
23:524 milligrams was superior to
23:54placebo for reducing binge eating.
23:57The remission rates at the categorical level
23:59in the three doses were not significant.
24:03The company, by the way,
24:04has decided not to do additional
24:06studies to pursue FDA approval.
24:08In terms of psychological treatment,
24:11a variety of focal manualized
24:14treatments are available.
24:15CBT interpersonal psychotherapy behavior,
24:17weight loss and a lot of folks
24:20have tried combining psychological
24:22and pharmacological treatments.
24:24Not going to show some of the
24:26data that are weaker,
24:27but I should highlight my clinical
24:30perspective that there is no support
24:32and I emphasize the no support
24:34for the common clinical war about
24:37integrating different treatments.
24:40One of the major studies that was
24:43published back in 2010 through the
24:45multi site study Wilson Wolfley
24:47in their sights alone Stanford.
24:49They found interpersonal psychotherapy,
24:51behavioral weight loss and cognitive
24:53behavioral therapy produced
24:54these effects which were roughly
24:5660% remission rates for.
24:58Call the remission rates.
25:01Precaution compare cross study,
25:02but we call it remission rates that I had
25:05noted for the pharmacotherapy Albany studies.
25:07So these were three different treatments.
25:09They are conceptually behaviourally and
25:12procedurally distinct focal treatments,
25:14but they produce 60% roughly remission
25:18rates and then after the these brief
25:22treatments was particularly impressive.
25:24Here are the durable effects,
25:26particularly for interpersonal
25:27psychotherapy and for cognitive
25:29behavioral therapy where the the.
25:31Benefits were very well
25:34sustained for two years.
25:37After the completion and
25:40discontinuation of the treatments,
25:41behavioral weight loss showed
25:43a little bit less durability,
25:46but still at 2 year follow up we
25:48still had 40% of people who were.
25:52Abstinent and that's nothing to sneeze about.
25:55This was one of our.
25:57Relatively early studies here at power.
26:01That compare cognitive behavioral
26:03and behavioral weight loss for BD.
26:06A little bit of historical context
26:09for this study and and some of this
26:12is beginning to resurface again.
26:14Which you know comes around
26:16goes around I guess.
26:17There for decades there were longstanding.
26:22Controversial in fact,
26:23rather heated claims by some
26:26groups that behavioral weight
26:28loss was not only ineffective,
26:29but might actually exacerbate binge eating
26:32and might exacerbate eating disorder.
26:34Psychopathology and those individuals
26:36who had excess weight or obesity
26:39and also had binge eating.
26:41Some of those models followed the
26:43early restraint models of excessive
26:45restrictive restraint leading to binge
26:48eating and a bunch of groups took that.
26:50And we're pretty passionate about.
26:53As being a contraindicated treatment,
26:56obesity feels I'm eating sort of
26:57fields were not really on the same
26:59page about this and I would get
27:00very different messages depending
27:01on which places I would go to,
27:04present findings, and so forth.
27:06I emphasize,
27:07for those of you who do not know
27:09that behavioral weight loss is
27:11not a rigid or restrictive diet,
27:13but it's rather a balanced,
27:14moderate lifestyle approach to
27:16eating and physical activity,
27:18and it's delivered within the
27:20context of a very solid learning
27:22theory and behavioral therapy.
27:25Platform, so we did this CBT versus
27:28BWL versus a third condition
27:30which was CBT followed by BW.
27:33Well we maximize the horse race so to speak.
27:37Given the historical context I provided and
27:40here are the findings of post treatment.
27:42Six month and 12 month follow
27:44up on the left side for percent
27:46limited on right side 4%.
27:50BMI loss at 12 month follow-up
27:53ITT remission rates were about
27:5650% for CBT and 36% for BWL.
28:02Mixed models analysis again.
28:04ITT revealed a significant
28:06advantage for CBT over BWL,
28:08for reducing binge eating and mixed
28:10models revealed a significant advantage
28:13for BWL over CBT for reducing weight
28:15at least through post treatment.
28:18The failure of CBT to produce
28:20any weight loss.
28:21Or essentially no weight loss is a
28:23consistent finding in our center and
28:25centers nationally and internationally.
28:27The findings we see here for BWL,
28:29have been replicated a number of times since.
28:35Before I go onto the new wave of studies,
28:39one criticism that I often hear about
28:42these kinds of manualized treatments is
28:44that you can do them in your specialized
28:47up sessional research clinics.
28:49But how do they apply to real world clinics?
28:53I don't buy that.
28:55Regardless of what I buy here,
28:56here at the data we did a study
28:58with the Yale Hispanic Center
29:00with the Yale Hispanic Clinic.
29:02Excuse me in which we delivered manualized
29:05behavioral weight loss treatment,
29:07which was a hybrid of our behavioral
29:09weight loss manual and the VP
29:12the diabetes Prevention Program
29:14behavioral Weight Loss Manual.
29:15The treatments were delivered in
29:18Spanish by the clinicians there.
29:21The patients there have every
29:24imaginable socio economic.
29:26And educational disadvantage and you
29:27see here a summary of the findings.
29:30Completion rates were over 80%.
29:33Patient did great.
29:34The clinician bought into the treatment.
29:36The patient brought into the treatment
29:38and the outcomes are outstanding with
29:40over 60% remission at post treatment
29:42and six months after the completion
29:45and discontinuation of treatment.
29:4750% of the patients were still
29:49absent from binge eating,
29:50so those are significant durable outcomes.
29:53My point here it is possible
29:55to train and it is possible.
29:56Disseminate these focal manualized
29:59treatments to real-world settings.
30:03Common question, well,
30:04these this is complicated.
30:06Should I take out the bazooka
30:08and combine treatments with
30:09more difficult patients?
30:14So far the answer is no.
30:16Adding pharmacotherapy to cognitive
30:17behavioral therapy has failed to enhance
30:20binge eating outcomes in six of the
30:22seven relevant studies published to date.
30:24Again, in a little while,
30:25we'll see some of ongoing studies where
30:27we have picked medications that have
30:29a little bit more clinical rationale
30:31are supposedly a bit more synergistic.
30:33From a mechanistic perspective in a
30:36story may change overtime, but so far,
30:38based on the available data,
30:40there is no noted.
30:42Notable advantage to adding
30:43pharmacotherapy to CBT for enhancing
30:46the binge eating outcome.
30:47Saying it goes for weight loss except for
30:51the CORDINO study which found at Pyro mate,
30:56significantly enhanced
30:57short term weight loss.
31:00Achievable CBT as well as enhanced the.
31:07The the binge eating outcomes.
31:09There's no, there's no support
31:11for combining as a way to enhance
31:14the behavioral treatments.
31:16The flip side is not true.
31:17We studied it produced that
31:18in the other direction,
31:19in which adding behavioral or
31:21cognitive behavioral to the
31:23pharmacotherapy did enhance both
31:25retention and clinical outcomes.
31:30Finally, to some of the
31:31work that we're doing now.
31:34Been trying and struggling with my
31:37colleagues to find new designs and
31:40RCT's that perhaps bear a greater
31:43resemblance to treatments and
31:45treatment approaches in real settings.
31:48A lot of the RCT's reviewed
31:51up until this point.
31:53The basic question is which
31:55treatment can help the most?
31:57Or which treatment can
31:59help the most patients.
32:01A lot of work in the past
32:02ten years in our field,
32:04another field has looked at step care models.
32:06These often consider scalable,
32:09less costly methods.
32:10Prior to moving on to more intensive
32:13treatments when there is an insufficient
32:16response, that's very logical.
32:17It makes sense.
32:18There are cost effectiveness
32:19reasons for doing that.
32:21They're scholarly reasons for doing that.
32:23The the National Institute
32:25of Clinical Excellence,
32:26the Nice guidelines in the UK,
32:29not very scholarly approach to guidelines.
32:32I feel, in fact,
32:34suggests that start with a guided self
32:37help form of cognitive behavioral therapy.
32:41And only if the patient
32:43doesn't benefit enough,
32:44you move on to a more intensive full
32:48blown and more expensive treatment that
32:50makes sense from a cost perspective.
32:52It might make sense from a
32:54broad community perspective.
32:55Make sense from an availability
32:57perspective there only so many
32:59specialist clinicians on and on but.
33:02As you'll see,
33:03there are some potential glitches to that,
33:05so one of the things we've been thinking
33:08about are more complex models of care.
33:10And instead of just the usual
33:12stepped care approaches,
33:13we've thought about some adaptive approaches,
33:16and this comes out of analysis
33:18that we've done with previous
33:20trials where we have looked at
33:22initial responses in patients,
33:24so coral so called early rapid response.
33:28As a way to guide subsequent clinical
33:31decision making and this also fits
33:33with an important development in
33:35several fields so called smart designs
33:38stands for sequential multiple
33:40assignment randomization trials.
33:44Early on, back in 2016,
33:47we published a paper in which we
33:49looked at the pattern of response
33:51to CBT and to phylloxera teen
33:54treatment for binge eating disorder.
33:56And we found that the majority of
33:59the treatment advances and benefits
34:00happened in the first two weeks.
34:05And then we did a variety of analysis
34:08and we found that this rapid response
34:11was highly predictive of who?
34:16Remitted at the end of treatment.
34:19But we also found that
34:20the pattern was differed.
34:22It was different for different treatment.
34:23So if you did not have a rapid response.
34:27Medication staying with the medication
34:29did not have any added benefit.
34:32If you didn't have an added.
34:34If you didn't have a rapid response
34:37to CBT and you stayed with CBT,
34:40there was kind of a sleeper effect
34:42and eventually you caught up.
34:43We have since replicated that in a
34:45variety of ways with a variety of
34:47treatments with the CBT findings
34:48being replicated over and over again.
34:50But importantly,
34:51we have found that for medication
34:53treatments with various medications
34:54that if you don't get a quick response.
34:57Better off switching the person
34:59sooner rather than later.
35:00Most clinicians I think.
35:01Well, let's let's wait a few more weeks.
35:03Let's wait a few more months
35:05that that I don't support that.
35:07But interestingly, we did an analysis.
35:10We did a couple of these.
35:11In fact,
35:12different trials with behavioral weight loss,
35:14and we found an interesting finding.
35:16If you had a rapid response
35:18to behavioral weight loss.
35:20That was highly predictive of of really
35:23good longer term outcomes in both binge
35:26eating remission and in weight loss.
35:29Remember,
35:29CBT does not produce weight loss.
35:32So that.
35:33Let us to this design.
35:36This is one of our first
35:38adaptive smart approaches to BD.
35:40We start on the left side of the figure
35:42with the first step care randomization.
35:45We randomized people to either VWL
35:47behavioral weight loss for six
35:49months as the standard treatment,
35:52the other condition we considered was
35:54obviously CBT as you Norma CBT guy,
35:56why did we pick BW?
35:57Well, two pragmatic reasons.
35:59BWL produces weight loss which
36:00is an important clinical outcome
36:02and and there are many many more.
36:04Clinicians trained in doing behavioral
36:06weight loss than they are in doing
36:10cognitive behavioral therapy.
36:11For better or for worse,
36:12that was our thinking. This step?
36:14Care randomization.
36:15We start people with behavioral
36:16weight loss for one month.
36:17At the end of one month we stopped
36:20and we see how people are doing.
36:22If they are doing great,
36:23we label those as as rapid responders.
36:28We had an algorithm based on
36:31several Roc analysis that we did
36:33with different trials before and
36:34we landed on a 70% reduction in
36:36binge eating by the 4th week as our
36:39marker for doing for doing well,
36:41and if they weren't doing well.
36:44We label them as non responders and
36:46we switched treatment so if they
36:47were doing well, it's not broken.
36:49Don't fix it,
36:49keep doing it and try to do it
36:51better so we continue with the
36:53beat up you well and we also
36:55randomized them to an obesity.
36:57I'm sorry.
36:57Weight loss medication what to
36:59a placebo and if they were not
37:01doing well we randomized them
37:02to an alternative treatment.
37:03Cognitive behavioral therapy guided
37:04self help with some people say treatment
37:07of choice sort of good place to start.
37:09And we also randomized them
37:11to weight loss. Medication.
37:14Or placebo in a double blind fashion.
37:16And then we followed them up.
37:19Our findings are summarized here.
37:21We had remission rates in the two conditions,
37:23which did not differ significantly
37:26of 74% and 67%,
37:27so we're getting a little bit better with
37:30this behavioral weight loss treatment.
37:33As we've seen this kind of
37:35steady creeping factor,
37:37so getting a little bit better each
37:40time we've refined our treatments
37:41based on some other lessons
37:42we've learned from each trial.
37:44And the right.
37:46Slide shows the remission rates
37:49within the different cells within
37:51the different step care arms.
37:54Adding the medication didn't
37:55seem to do much with either.
37:58The people who had an initial response
38:00and did not have an initial response
38:02in terms of weight loss is the left
38:05slide shows the overall findings from
38:07step care versus behavioral weight loss,
38:09and you see that the treatments did
38:11not change did not differ either
38:13in terms of the time course of
38:15weight or the outcome at the end.
38:16Six month treatments.
38:18The right slide,
38:20which is beyond today's scope
38:22for good obsessional,
38:23does look at some people who did.
38:27Depending on which treatment they were in,
38:28adding a weight loss medication did help.
38:31Some of the weight loss,
38:33which is fairly logical,
38:34but overall it did lead to
38:36a difference with the.
38:37With the standard treatment.
38:40Good news is 6 months,
38:4212 months after the completion
38:45of discontinuation of these.
38:50These treatments,
38:51the remission rates, were fairly well.
38:54They're not at quite in that
38:56same stratosphere of 67 and 74%,
38:59but remission rates were still
39:0245% and 41% at 12 months,
39:05which is not differ significantly between
39:07the standard and it's destep care.
39:09Mixed models of binge eating frequency.
39:11So binge eating frequency,
39:13considered continuously.
39:14We're also not significant between
39:16the two treatment conditions and,
39:18importantly, to drop off.
39:19From post to 12 month follow-up
39:22was not significant.
39:2512 month follow up at percent
39:27weight loss in the step care.
39:30I was a little bit less than the
39:33behavioral weight loss where we
39:35actually hit a mean of 5% weight loss.
39:39At 12 months after treatment,
39:415% is often used as a marker in the
39:43obesity field as potentially approaching
39:45a clinically meaningful amount of weight.
39:52We then designed this study.
39:57Funded by NIH, in which we are finally
40:01getting to the point where we have.
40:04Different artillery available to us,
40:06so we now have medications that seem
40:09to potentially have greater benefit for
40:11conceptually addressing the binge eating,
40:14and more importantly,
40:15they are a little bit more potent
40:17for producing weight loss,
40:19and that can be tolerated.
40:21This is a study with naltrexone
40:24bupropion combination medication
40:25that's FDA approved for weight loss.
40:28In this study, we had a balance
40:31two by two factorial design, so.
40:34You get behavioral weight loss,
40:36yes or no.
40:36You get naltrexone,
40:37be appropriate or placebo in
40:40double blind fashion that heals for
40:43treatment conditions and the treatment
40:45conditions went on for 16 weeks.
40:47The behavioral weight loss by a
40:50doctoral clinicians followed protocol
40:52that had been well established.
40:54Treatments with done well.
40:57No,
40:57I didn't hear 2 manuals and and and
41:00so forth and then at the end of the
41:03six weeks we conduct a post treatment
41:05assessment and we see how they're doing.
41:08If they responded to the initial
41:10stage one treatments we?
41:12Re randomize them to naltrexone placebo,
41:16or to placebo.
41:17This, as answer the very important question,
41:20which, remarkably,
41:21there is a dearth of data
41:23available for clinicians.
41:24Which is,
41:24if you have a patient who
41:26has responded to treatment.
41:27Just keeping them or putting them on
41:30a weight loss medication help them to
41:35maintain their progress remarkably,
41:37there's only one randomized control
41:40test of a maintenance medication for BD,
41:44and I was with LDX and LDX continuing
41:47after the two treatment did
41:49significantly reduce the chances of relapse,
41:52so this is only the second such study.
41:55We didn't have an exploratory arm
41:56that what do you do with the people
41:59who don't benefit to these two?
42:00Presumably decent treatments.
42:02One of the FDA approved medication and BWL.
42:05I showed you all the data before.
42:06Well here we switched them to CBT
42:09here we learned from the previous.
42:12Design where we switched them
42:14to cognitive behavioral therapy.
42:15Guided self help.
42:16I was perhaps overly influenced by
42:18Nice because I went to guided self
42:20help but didn't seem to do enough.
42:22So here we switch him to the full
42:24blown CBT to see if that helps
42:26the non responders.
42:29Yeah, findings for you.
42:30This is hot off the press.
42:32We just did the analysis
42:33over the last couple weeks.
42:34Thank you relypsa.
42:37We randomized 136 patients with PD
42:40and obesity and here are the remission
42:42rates at the end of treatment on
42:45the left side in the blue box,
42:47remission rates were significant for
42:50behavioral weight loss and for naltrexone,
42:52but the interaction was not significant.
42:55When you consider the four cell design
42:57in each of the active treatments were
43:00significantly superior to placebo.
43:02I do not show a graph here
43:04for binge eating frequency,
43:06but we saw the same rapid response
43:09in binge eating frequency.
43:11The decrease was significant for
43:14being for behavioral weight loss.
43:17It was not significant for naltrexone
43:20bupropion nor was the interaction
43:23significant the right slide.
43:25So shows 5% weight loss categories.
43:27The rate was the proportion meeting
43:30this category was significant for BWL.
43:33But not not trackson be propri
43:36on and percent weight loss.
43:38Considered continuously,
43:38however,
43:39was significant for BWL and for
43:41now tracks don't be propri on as
43:44well As for an interaction effect.
43:45Again there wouldn't consider weight
43:47loss as a percent continuously.
43:50Each active treatment with
43:53significantly superior to placebo.
43:56We do not yet have the findings
43:58were nearly done with the stage
44:01two trial on whether behavioral
44:03now trackson bupropion is superior
44:05to placebo for preventing relapse.
44:08Hopefully we can present that
44:10down down the line,
44:11but that's one of the
44:12things we're looking at.
44:13And we are also looking at ultrex
44:16zone bupropion versus placebo
44:17in a different study.
44:19This is with our colleagues in.
44:22Sherry Mackey's groups there,
44:24that's a straight medication versus placebo,
44:29designed with slightly more folks allocated
44:32to the two medication conditions,
44:34and she has embedded a nifty laboratory.
44:40Eating paradigm to look at
44:44behavioral and metabolic.
44:46Correlate's,
44:47and as moderators and potential
44:49mediators have changed with
44:51the medication treatment.
44:55This is another ongoing smart design that
44:58we have when we talk you through the.
45:02Through the treatment. Come sell here,
45:05this is a straight horse race from the
45:08supposed leading treatments for BDL.
45:10DX is the soul. Medication approved
45:14by the FDA for binge eating disorder.
45:17CBT is in in most guidelines and most
45:20meta analysis and reviews considered
45:23the leading psychological treatment
45:25for BDD and we then did CBT plus LDX.
45:30There is no control,
45:32no placebo condition here as
45:35both active treatments have.
45:37Clearly demonstrated efficacy and
45:39effectiveness in variety of setting.
45:43The study here is how to
45:46compare the two treatments.
45:48The three treatments overtime.
45:51Three month treatments.
45:52That's the labeling for the LDX we
45:55have manuals for CBT for 12 weeks,
45:5820 weeks, 24 weeks and our effects.
46:01Our comparable so the treatments
46:03are nicely matched in that way.
46:05At post treatment we assess again
46:08a response based randomization.
46:10If you were in either of the
46:13LDX medication treatments,
46:14you get re randomized.
46:16If you were a responder to either LDX
46:20or to placebo to see whether LDX.
46:23Is superior to placebo
46:24for preventing relapse.
46:25This would be a replication of the
46:27Hudson and all the sole report
46:29in the literature that was in
46:31JAMA Psychiatry suggesting that
46:32the medicine prevents relapse.
46:34If you were a non responder here,
46:37we had much debate here with you.
46:41Assign them to.
46:42We took a cookie cutter approach.
46:44We assign them to a different medication
46:46that has a completely different.
46:51Mechanism of action if you will.
46:52So we chose naltrexone,
46:55bupropion and our comparison condition
46:58over the stage two is CBT that had
47:01received CBT without any medication.
47:04They received no further intervention,
47:07and then we assess them at post
47:09treatment and then at 6 and 12
47:12months after this continually discuss
47:14discontinuing the second stage treatments.
47:16We do not have the findings for you.
47:18As of yesterday.
47:19I believe we had 84 people.
47:21Randomized and nearly completed
47:23treatment and stage one,
47:26but we don't have those
47:28outcomes to share with you yet.
47:32Much of our work is evolved in
47:35terms of trying to predict and
47:37understand treatment outcomes.
47:39One of the most common questions
47:41that I get asked is, you know,
47:44most of my patients have
47:46comorbidity with treatments.
47:47Should I use should I combine?
47:48Should I add medications?
47:50This is analysis that Janet
47:53Whitaker and I did.
47:54Australia this year.
47:55Last year I should say.
47:57And we examined psychiatric comorbidity
47:59as a predictor and moderator or treatment
48:02outcomes and an aggregated sample.
48:04636 patients with BD who had received CBT,
48:07behavioral weight loss medication,
48:08plus therapy and controls
48:10comorbidity predicted,
48:11worst BD outcomes overall
48:13and across treatments but did
48:16not interact with treatments.
48:17And it did not moderate binge
48:20eating nor weight loss treatments.
48:22So there's some evidence that if
48:24you have a mood disorder you may do.
48:26More poorly overall.
48:29But that does not signal the
48:31need for a combined treatment
48:32or for a specific treatment.
48:34I will remind you, however,
48:36that this analysis,
48:37the overall finding included
48:38control conditions.
48:39We do not find this kind of effect
48:42from major depression or for
48:44depression considered dimensionally.
48:46Using a variety of rating scales as a
48:49significant predictor or moderate are.
48:50So that's I think a fairly definitive
48:53answer to one of the most common
48:55questions that is asked of me,
48:57particularly by clinical psychiatrist.
49:01Another way that we have tried
49:05to predict treatment is here.
49:07Earlier on I indicated that finding
49:10reliable predictors of treatment and I just
49:12showed you the the comorbidity findings,
49:14which is a logical clinical thing to
49:17look at to people comorbidity to worse.
49:19Overall they do not and they certainly
49:21don't point to a specific available
49:23treatment that we have tested today.
49:28A different way.
49:31Again, we have found one reliable
49:34treated predictor which is
49:36actually a treatment process,
49:37and that's rapid response,
49:39which is why we built these smart
49:41designs around that our reliable
49:43predictor and the overvaluation of
49:45shape and weight was the only other
49:48thing a body image criterion that
49:51predicted some outcomes in some trials,
49:55and it actually moderated CBT
49:58versus peroxide treatments.
50:00Effects in a different trial,
50:03but for the most part finding reliable
50:05predictors have been hard, so.
50:09A different way to do this is maybe
50:14computers are smarter than us.
50:16Clinician so we tried some
50:18machine learning models.
50:21And the answer is they didn't do
50:24much better. But why did we do this?
50:29A lot of field anxiety, some.
50:33Depression, some dangerousness
50:35domains people have been using
50:37machine learning models to try
50:40to predict what has is generally
50:42viewed as hard to predict outcomes.
50:44Machine learning is in contrast
50:45to the way we've done our
50:47predictor and moderator analysis,
50:48where we have either theoretical or
50:52clinical variables chosen based on.
50:56Some kind of model that should be
50:58associated with the treatments or
51:00with the outcomes machine learning
51:02rely on patterns in the data.
51:04So you don't have these apriori
51:08kinds of concepts.
51:09Which might be theoretically smart,
51:11or they may be biased in one point view,
51:15but they learn patterns of data and then
51:18they can generate and optimize models.
51:22Are there ways to enhance
51:23generalizability of those models by
51:25doing a whole bunch of what they
51:27refer to as cross validation attempts,
51:29which in English means you can run a
51:32whole bunch of different simulations?
51:34And the other advantage to machine
51:36learning is you can throw many
51:39more variables into the models,
51:41and in fact the more variables the
51:43better because it just turns and turns
51:45and turns and finds optimal combinations.
51:48If there are so it actually benefits
51:51from having many conditions.
51:53This is not a panacea,
51:55and I think the fields are trying
51:58are finally coming around to
51:59seeing that and some of the early.
52:02You know great findings that some of
52:04these machine learning models found
52:06were because how they did some of the
52:09simulations and most of the ones that
52:12provided these great benefits for.
52:16And we wrote about it a little bit
52:18in in this paper in Psychological
52:20Medicine published last year.
52:22If you use certain types of simulations,
52:24and you in particular certain
52:28bootstrapping in methods such as
52:30optimism corrected bootstrapping,
52:32you can overinflate things.
52:33So we just did this as
52:36a math exercise awhile.
52:38We also used the regular regression
52:40approach to look at some of the clinical
52:43variables based on our clinical models.
52:45And machine model machine learning
52:47models didn't have much advantage
52:48over our regression models.
52:50The area under the curve across the
52:52different approaches was was poor to fair.
52:57The the better way of doing these models,
53:00I think, is with unbiased resampling
53:02methods and they really had minimal
53:04advantage over our traditional models.
53:06So this is some of the ways in which
53:08we you know we tried to think a
53:10little bit outside the box and to
53:12identify predictors of outcome which
53:14would really help us come up with
53:16better ways to target our treatments.
53:18And and to know ahead of time who who
53:20needs more attention and so forth.
53:22I will note that the analysis
53:24across different ways did converge
53:26in a couple notable ways.
53:28Rapid response again emerged
53:30as a rather robust predictor.
53:33And then importantly,
53:35we bias internalization.
53:38Which I highlighted early on in
53:40my talk on my sofa box about being
53:42respectful and polite to people.
53:44Because they couldn't internalize
53:46some of these negative attitudes.
53:49Predicted poor binge eating and.
53:53Eating disorder psychopathology outcomes.
53:57Another approach that we tried
53:58to use to kind of understand.
54:03How treatments work.
54:06Before I mentioned network analysis,
54:08this is a network analysis.
54:11It's performed this is hot off
54:14the press and under review.
54:16Reason to do this is.
54:18A lot about predictor analysis.
54:20Have looked at predicting intensities
54:23or outcomes of the symptoms.
54:26And this is an approach where we can
54:28look at how does treatment impact
54:30the way that symptoms are kind of
54:34interconnected or related to one another.
54:37And again you have.
54:40If you look at the the left side,
54:42the first blue.
54:45Figure is what the network looks
54:47at Pretreatment II blue figure
54:49what the network looks like.
54:50It's at post treatment and then this
54:53the the final blue figure is what the
54:56network looks like at post at 12 month.
54:59Follow up the post and the follow up
55:01were very similar to one another.
55:03The indices for that are in those
55:06squares there and to take home message
55:09here is at pretreatment overvaluation.
55:13Was the most central.
55:18A feature. And remember,
55:20I had highlighted that in a different
55:23analysis earlier on in a talk,
55:25so before treatment over valuation.
55:29What is the most Australian feature and
55:32you can see that in the right figure
55:35for over valuation in the green dot?
55:38At the end of treatment and at follow up.
55:43This satisfaction had the highest centrality,
55:46and you can see that in the right figure
55:49towards the bottom of the two circles
55:52that are way out towards the right.
55:54So the way to interpret this
55:57is not so much that we.
56:00I reduced overvaluation of shape and
56:02weight because you can't really say
56:04that in a valid way given some of the
56:08in's and outs of these analysis and
56:09some of the concepts in the math.
56:11And you also shouldn't say clinically
56:13that we, oh, great job Grillo,
56:16you, you and your team there.
56:17You increase the satisfaction
56:18with Wade and shape.
56:19That's not what's happening here.
56:21What's happening here?
56:22Is the relationships among the symptoms
56:24and the features of the disorder
56:26and what I will highlight is if you
56:29look at those squiggly lines there
56:30and you match them up with network
56:33analysis of similar constructs in
56:35people without eating disorders,
56:37they look rather similar.
56:43Other ways in which we
56:44are looking at treatment.
56:45Let me just go back.
56:48Is I mentioned? This study,
56:52Doctor Potenza group and I have
56:56a have an NIH grant grant in
56:58which we are integrating F MRI.
57:04Protocols before and after treatment,
57:06along with neurocognitive testing
57:07before and after treatment,
57:08also is a way to look at both predictors,
57:11but also potential moderators of treatment,
57:15neurobiological and or psychiatric
57:17moderators of treatment and by looking
57:20at some of the changes that occur.
57:24We will gain glimpses into potential
57:27mediators and mechanisms of the change,
57:30and that could also eventually guide him
57:34more rational approach to ahead of time.
57:37Telling a patient well.
57:38Yeah, CBT and have LDX given
57:42this this and this.
57:43I would suggest this for you,
57:45so that's another area that hopefully.
57:48Will have the opportunity to report
57:50to you at some point in time.
57:54So in summary.
57:58Please recognize the
57:59broader context of obesity,
58:01stigma and chain and shame and the
58:04important body image constructs.
58:06Big take home message for patients is
58:08that there are effective treatments.
58:10These treatments,
58:10some of them can help very quickly.
58:13On average our patients have
58:14suffered in silence without coming
58:16for treatment for over 10 years.
58:17That's consistent with epidemiologic data
58:19regarding long persistence and duration.
58:21Of these problems when they go untreated,
58:24our treatments often help
58:25people within a month.
58:27So there are effective treatments and
58:29some can help quickly pharmacotherapy.
58:31There's only one FDA approved
58:33medication down the X,
58:34or the others would be using off
58:36label and presented some of that,
58:37or regarding utility to
58:39pirate made for some people,
58:41even though that's a tricky medicine,
58:42it's hard to get people up to 300,
58:43four, 100 milligrams, which you have,
58:45which is what you have to do.
58:46But if you can,
58:47does have some nice outcomes,
58:48at least over the short term.
58:50Psychological treatments include
58:52several specific evidence based
58:54focal manualized treatments,
58:55most notably CBT, IPT,
58:57and behavioral weight loss.
58:59And what you see with those treatments
59:01is that over 50% of the patients
59:03seem to benefit a great deal,
59:04and they have durable outcomes over
59:06two to five years follow up and in
59:09pharmacotherapy to CBT and behavioral
59:10weight loss has generally failed to
59:12enhance either with the medications
59:14that have been tested to date,
59:15but emerging research as
59:17I presented from our lab,
59:19is testing combination approved
59:21approaches using new medications that,
59:24from a mechanistic perspective,
59:25should have a greater synergistic effect.
59:28And we're working on coming up with
59:30treatment research to integrate
59:32methods to identify predictors,
59:34moderators, and processes of change,
59:36and we hope that this would lead
59:38to more rational prescription
59:40of truth treatments over time.
59:43I am quite indebted to my colleagues
59:46at power like to acknowledge Dr.
59:49Lydecker and or my associate directors,
59:53our faculty. These are our current faculty.
59:56We have many faculty who have left us
59:58for their own programs and leadership
01:00:01positions here and elsewhere.
01:00:03These are our current faculty and most
01:00:06indebted to them for their collaborations.
01:00:09We also have a number of study physicians
01:00:13and coinvestigators gentek under Johnston,
01:00:15Prof and Jorge Moreno.
01:00:17And here we have our medical input
01:00:20comes as represents psychiatry,
01:00:23endocrinology and internal medicine so.
01:00:26It's a very rich.
01:00:30And stimulating.
01:00:36Constant discussions and then
01:00:38I'll postdoctoral associates.
01:00:39These are our current Coast postdoctoral
01:00:42associates who deliver the treatments
01:00:45faithfully at a very high level.
01:00:47Our retention rates are remarkable.
01:00:49Both of completion treatments as well
01:00:51As for the completion of retention,
01:00:53follow-up assessments, and then,
01:00:54through our pre doctoral
01:00:56and research assistants,
01:00:58who somehow keep the machinery
01:01:00of the bazillions of pieces of.
01:01:03Of of data in an organized way,
01:01:05and we don't let people fall through
01:01:07the cracks and we get everything
01:01:09done that we need to get done
01:01:11and we are most appreciative of
01:01:13their efforts and finally to the
01:01:16thousands of patients who have.
01:01:21Come to us for help and have
01:01:23been most generous of their time,
01:01:25and they've had the courage to share
01:01:27with us and reach out for help.
01:01:29But then,
01:01:30even long after the treatments are done,
01:01:32they stay in touch with us and
01:01:33how long follow-up studies to let
01:01:35us know what's going well and
01:01:36what's not going so well.
01:01:38And that's the only way we can
01:01:39get a little bit better at
01:01:40doing what we're trying to do.
01:01:42We need to get better,
01:01:43so we really appreciate the giving
01:01:45of these patients as they share these
01:01:48very private and sensitive issues with us.
01:01:50Before I take questions.
01:01:51Put in a plug for one of our studies.
01:01:54Any of you have in various
01:01:56clinics and programs.
01:01:57People who might have binge
01:02:00eating disorder or concerns.
01:02:03Here's one of our Flyers.
01:02:04We thank YCCI for their excellence
01:02:07in creating good Flyers.
01:02:09The language we use there,
01:02:10by the way, was carefully.
01:02:12An obsession really thought out.
01:02:14Given several studies that we did
01:02:15in terms with our patient groups
01:02:17and different settings and times in
01:02:18the course of their illnesses to
01:02:20figure out what kinds of language
01:02:21in terms they find least offensive.
01:02:24So thank you very much.