Two novel treatments to reduce overeating in overweight children: a randomized controlled trial.

Current data suggest that 32% of children in the United States are overweight or obese (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). To date, the gold standard treatment of childhood obesity is behavior therapy, typically provided to parents and child, weekly for 4 – 6 months. Family-based interventions that combine nutrition education and exercise with behavior therapy techniques (Epstein, 1996) are considered the most effective methods for weight loss. Ten-year longitudinal data show that one third of children who receive behavioral treatment are no longer overweight in adulthood (Epstein, Valoski, Wing, & McCurley, 1990). Although accumulated data from the past few decades have provided a solid basis of support for behavior therapy, not all children respond and other options for treatment are needed. Reasons for nonresponse to behavioral obesity treatment are unclear. It is possible that the effects of biological and environmental factors cannot be overcome through behavioral therapy or that people who are overweight or obese are a heterogeneous group who do not respond to a single treatment. Thus, it is imperative to develop additional approaches to treat overweight and obese children in order to maximize efficacy for a larger number of patients. One potential approach is to develop specialized interventions for subgroups in which causal and maintenance mechanisms of obesity are targeted. Because obesity is caused by an imbalance in caloric intake and energy expenditure, treatments that reduce overeating could be a viable intermediary target to intervene on weight gain during youth. One subtype of children that might benefit from targeted treatments is children who eat in the absence of hunger. Eating in the absence of hunger (EAH) is thought to represent a stable phenotypic behavior (Fisher & Birch, 2002; Francis, Ventura, Marini, & Birch, 2007). EAH is a behavioral measure of food consumption beyond subjective ratings of satiety. EAH is measured with a laboratory paradigm and has been linked to parent's restriction of food (Birch & Fisher, 2000; Birch, Fisher, & Davison, 2003; Fisher & Birch, 1999a), maternal prepregnancy weight (Faith et al., 2006), parent weight status (Francis et al., 2007), and maternal disinhibition of eating (Cutting, Fisher, Grimm-Thomas, & Birch, 1999). Most important, high EAH has been found to be associated with a 4.6 times increased risk for overweight at both 5 and 7 years of age (Fisher & Birch, 2002). Based on these data, EAH appears to be a viable target for treatment, and reduction in this type of overeating in childhood could reduce caloric intake and influence current or future obesity status during youth. EAH is proposed as a key symptom that contributes to an episode of binge eating (Marcus & Kalarchian, 2003) and can be assessed with the laboratory paradigm described above or by the Eating Disorder Evaluation standardized interview for children (chEDE; (Bryant-Waugh, Cooper, Taylor, & Lask, 1996; Fairburn & Cooper, 1993). The chEDE is used to evaluate overeating (objective and subjective) and the subjective experience of loss of control while eating, in order to diagnose binge eating and other eating disorders. The chEDE yields three subscales related to binge eating, including Objective Bulimic Episodes (OBEs; objective binge eating and loss of control), Objective Overeating Episodes (OOEs; objective binge eating without loss of control), and Subjective Bulimic Episodes (SBEs; subjective binge eating with loss of control). Thus, conceptually, EAH and OBEs, OOEs, and SBEs should be highly correlated. However, the OBEs, OOEs, and SBEs are self-reported in an interview, and the evaluation of EAH is based on a laboratory paradigm. To date, no studies have evaluated the concordance between the EAH paradigm and the interview assessment of binge eating in children. Conceptually, decreasing EAH should yield a decrease in calories, which could result in decreased weight gain over time. Schachter's externality theory of obesity (Schachter, 1971; Schachter & Rodin, 1974) states that obese humans are more reactive to external cues to eat (e.g., time, presence and quality of food, situational effects) and less sensitive to internal hunger and satiety signals than their lean counterparts. If the externality theory has validity, children who are more reactive to external cues to eat and less sensitive to internal cues to eat would display eating in the absence of hunger behavior. In general, there is mixed support for the externality theory, as older research failed to demonstrate that overweight individuals are more responsive than their normal weight peers to external cues (Hibscher & Herman, 1977; Hill & McCutcheon, 1975; Meyers, Stunkard, & Coll, 1980; Rodin & Slochower, 1976; Storms & Nisbett, 1970) and more recent data support enhanced food cue sensitivity in overweight children and adults (Ferriday & Brunstrom, 2010; Jansen et al., 2003). It is possible that overweight individuals represent a number of behavioral phenotypes, and etiological models such as externality theory may prove useful for defining distinct subgroups. The increased reactivity to external cues could be considered a learned response (Gibson & Desmond, 1999). Cues that accompany food—such as the sight, smell, and taste of food; rituals for eating; environment; as well as affective states and food-related cognitions—can be conditioned through Pavlovian learning to elicit physiological responding (Jansen, 1994, Jansen, 1998). In a Pavlovian conditioning model, food intake may be considered an unconditioned stimulus, whereas the metabolic responses (e.g., salivation, insulin release) are unconditioned responses. Over time, cues that signal food intake, such as sight and smell of food, may start to act as conditioned stimuli, which can trigger conditioned responses (e.g., food consumption after viewing a food commercial). Thus, learned cue reactivity could increase the probability of overeating (Jansen, 1994, Jansen, 1998). In principle, the association between urges to eat and external cues should be amenable to extinction through systematic exposure (Wardle, 1990). Systematic exposure has shown efficacy with drug and alcohol addictions and could logically be applied to the treatment of EAH in children. Treatments that reduce sensitivity to external cues, such as cue exposure treatment and exposure with response prevention, have been found to decrease cue reactivity in alcohol usage (Drummond & Glautier, 1994; Monti & Rohsenow, 1999), drug usage (Childress et al., 1993; Franken, de Haan, van der Meer, Haffmans, & Hendriks, 1999), nicotine usage (Havermans, Debaere, Smulders, Wiers, & Jansen, 2003; Niaura et al., 1999), and purging (Bulik, Sullivan, Carter, McIntosh, & Joyce, 1998; Carter, Bulik, McIntosh, & Joyce, 2002; Toro et al., 2003). These programs attempt to decrease sensitivity to external cues by extinguishing the relationship between the conditioned stimuli and the unconditioned stimuli, in the presence of the triggering cues. Cue exposure treatments interventions could be used to decrease a child's reactivity when faced with potential binge foods, thus decreasing EAH. The other target of treatment for overeating in children indicated by Schachter's theory is increasing sensitivity to internal cues of eating and satiety. Appetite awareness training focuses on training participants to regulate their eating by responding to hunger and appetite. This program has been shown to decrease the frequency of binge eating in adults (Craighead & Allen, 1995) and has shown promise with overweight children (Bloom, Sharpe, Heriot, Zucker, & Craighead, 2005). Additionally, a study that focused on enhancing awareness to satiety with preschoolers showed a decrease in overeating following a 6-week program (S. L. Johnson, 2000). These studies suggest that children can potentially respond to training that focuses on responding to internal cues of hunger and satiety and that these programs have the potential to decrease overeating. In summary, behavioral treatments for childhood obesity show a long-term response in one third of children. However, not all children respond to behavioral treatment. In accordance with the externality theory of obesity, it is possible that two treatments may hold promise for intervening with children who eat in the absence of hunger: cue exposure treatment–food and appetite awareness training. Thus, our purpose in this treatment development study was to evaluate the efficacy and acceptability of these two treatments on overeating and weight gain with children who eat in the absence of hunger.