Yale Psychiatry Grand Rounds: January 7, 2022

January 07, 2022

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"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.