expert roundtables

Specific Eating Behaviors as Potential Treatment Targets in Chronic Weight Management

by Caroline M. Apovian, MD, FACP, FTOS, DABOM, George A. Bray, MD, F. Xavier Pi-Sunyer, MD

Overview

In combination with lifestyle modification and diet, pharmacotherapy has been shown to have the potential to improve weight-loss outcomes in obesity by reducing the negative psychological and biological consequences associated with dieting, assisting with positive behavior change, and increasing self-control. Food cravings are associated with obesity and weight-related outcomes, and being able to control food cravings may determine adherence to a healthy low-fat or low-carbohydrate diet. Food cravings, eating restraint, and hunger can be effectively determined in obese patients with such tools as the Three-Factor Eating Questionnaire (TFEQ). Pharmacotherapies for chronic weight management have different effects on appetite expression, eating behavior, and central nervous system activity. Increased research and understanding of appetite regulation and cravings and the neural activity underlying the lack of dietary control have provided potential targets for some US Food and Drug Administration–approved medications for chronic weight management, with naltrexone/bupropion, lorcaserin, phentermine and liraglutide showing promise in targeting food-craving eating behaviors in clinical studies. One randomized trial demonstrated that the glucagon-like peptide-1 receptor agonist liraglutide alters the circulating levels of hormones that are important in energy homeostasis and influence perception of food cues and cravings in the central nervous system. The authors of a functional magnetic resonance imaging (fMRI) study of responses to food cues reported that naltrexone/bupropion administration leads to increased activity in inhibitory control–related areas and reduced activity in the hypothalamus. Studies have shown that the selective 5-HT2Creceptor agonist lorcaserin reduces food intake and decreases hunger, and fMRI demonstrated decreased activity in attention-related neural regions along with reduced emotional- and salience-related limbic activity. Medications that target food cravings can effectively assist long-term weight loss and improve obesity-related complications. Our featured experts in the field discuss how specific eating behaviors may influence the choice of treatment in chronic weight management.

Q: Are there specific eating behaviors that influence your choice of pharmacotherapy? 

F. Xavier Pi-Sunyer, MD

Professor of Medicine, Institute of Human Nutrition
Co-Director, Columbia Obesity/Nutrition Research Center
Columbia University
New York, NY

“Liraglutide does seem to work on hunger, and this might be more important in some people with obesity who state that they are always hungry vs patients who report having trouble with satiety.” 

F. Xavier Pi-Sunyer, MD

Xavier Pi-Sunyer, MD
Professor of Medicine, Institute of Human Nutrition
Co-Director, Columbia Obesity/Nutrition Research Center
Columbia University

It is difficult to analyze the cause of the obesity and specific eating behaviors and to determine a specific drug that will help the patient. Liraglutide does seem to work on hunger, and this might be more important in some people with obesity who state that they are always hungry vs patients who report having trouble with satiety. Therefore, there are some choices that you can make on medication treatment based on appetite and food cravings, but they are quite limited. 

George A. Bray, MD

Boyd Professor Emeritus, LSU, 
Pennington Biomedical Research Center, 
Louisiana State University, 
New Orleans, LA

“People who had a strong craving for carbohydrates did not lose as much weight as those who did not, and individuals who had a craving for high-fat foods actually had more weight loss. Thus, there may be some relationships between weight loss and food preferences.” 

George A. Bray, MD

Dr Bray:
Boyd Professor Emeritus, LSU
Pennington Biomedical Research Center
Louisiana State University


Data from the Preventing Overweight Using Novel Dietary Strategies (POUNDS LOST) study may provide some clues. In that study, we used the TFEQ, which measures disinhibition and food preferences. We found that restrained eaters on this test lost less weight that those who were not restrained eaters. A food craving inventory was also predictive of treatment response. People who had a strong craving for carbohydrates did not lose as much weight as those who did not, and individuals who had a craving for high-fat foods actually had more weight loss. Thus, there may be some relationships between weight loss and food preferences. There are some factors that may make a difference in your ability to predict how people respond to diets based on their preliminary eating evaluation. There are at least 2 potentially useful questionnaires. There is 1 that measures food craving and there is the TFEQ. I think that they might both be something worth including so that we can get a little more quantitation in the field, but it is difficult.

Caroline Apovian, MD, FACP, FTOS, DABOM

Director, Nutrition and Weight Management
Section of Endocrinology, Diabetes, and Nutrition
Boston Medical Center
Professor of Medicine, Boston University School of Medicine
Boston, MA

More quantification is definitely needed in obesity, and the TFEQ can certainly help us. I have got to get this into our clinic because we are not using it now as a tool, but what doctors, nurse practitioners, and dietitians are, in fact, doing when they interview the patients is basically asking the questions included in the TFEQ and making treatment recommendations based on that interview. Therefore, the treatment recommendations are based on food cravings and other measures in the TFEQ. Using this tool would be useful in terms of being consistent. Then, we would be able to publish the findings and move the field of chronic weight management forward to use an organized questionnaire such as that.

References

Bohrer BK, Forbush KT, Hunt TK. Are common measures of dietary restraint and disinhibited eating reliable and valid in obese persons? Appetite. 2015;87:344-351.

Farr OM, Tsoukas MA, Triantafyllou G, et al. Short-term administration of the GLP-1 analog liraglutide decreases circulating leptin and increases GIP levels and these changes are associated with alterations in CNS responses to food cues: a randomized, placebo-controlled, crossover study. Metabolism. 2016;65(7):945-953.

Farr OM, Upadhyay J, Gavrieli A, et al. Lorcaserin administration decreases activation of brain centers in response to food cues and these emotion- and salience-related changes correlate with weight loss effects: a 4-week-long randomized, placebo-controlled, double-blind clinical trial. Diabetes. 2016;65(10):2943-2953.

Martin CK, Redman LM, Zhang J, et al. Lorcaserin, a 5-HT(2C) receptor agonist, reduces body weight by decreasing energy intake without influencing energy expenditure. J Clin Endocrinol Metab. 2011;96(3):837-845.

Rebello CJ, Greenway FL. Reward-induced eating: therapeutic approaches to addressing food cravings. Adv Ther. 2016;33(11):1853-1866.

Roberts CA, Christiansen P, Halford JCG. Tailoring pharmacotherapy to specific eating behaviours in obesity: can recommendations for personalised therapy be made from the current data? Acta Diabetol. 2017;54(8):715-725.

Wang GJ, Tomasi D, Volkow ND, et al. Effect of combined naltrexone and bupropion therapy on the brain’s reactivity to food cues. Int J Obes (Lond). 2014;38(5):682-688.

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