Riccardo Dalle Grave

Behavior therapy for nonalcoholic fatty liver disease: The need for a multidisciplinary approach†‡

Nonalcoholic fatty liver disease (NAFLD) is systematically associated with insulin resistance and the metabolic syndrome, where behavior therapy remains the primary treatment, simultaneously addressing all the clinical and biochemical defects. However, very few studies have tested the effectiveness of intensive behavior therapy in NAFLD, aimed at lifestyle modifications to produce stable weight loss by reduced calorie intake and increased physical activity. Searching the literature for studies testing weight loss and lifestyle modifications for the treatment of NAFLD, only 14 reports were traced where the entry assessment satisfied well‐defined criteria. The final effectiveness was based on hard histological outcomes in 5 cases. All but 1 were pilot, uncontrolled studies or limited case series, and in general the details of treatment were scanty. In only 3 cases treatment was carried out along the guidelines of behavior treatment to reduce excess nutrition and increase exercise; in these cases, a remarkable effect on weight loss and an improvement in liver histology were reported. The principles of behavior therapy are presented in detail, to help physicians change their prescriptive attitude into a more empowerment‐based approach. A brief section is also included on the practical aspects and public policies to be implemented at societal level to obtain the maximum effects in lifestyle changes. There is a need for multidisciplinary teams including dietitians, psychologists, and physical activity supervisors caring for patients with NAFLD. Alternatively, general practitioners and physicians working in gastrointestinal units should limit their intervention to engage patients with NAFLD before referral to specialized teams set up for the treatment of diabetes and obesity. (HEPATOLOGY 2008.)

Compulsive exercise to control shape or weight in eating disorders: prevalence, associated features, and treatment outcome

OBJECTIVE The study was aimed at assessing the prevalence of compulsive exercising to control shape and weight in eating disorders (EDs) and its relationship with treatment outcome. METHOD Compulsive exercising to control shape and weight, defined according to a modified version of the Intense Exercising to Control Shape or Weight section of the Eating Disorder Examination (EDE), was assessed in 165 consecutive ED inpatients entering a protocol based on the transdiagnostic cognitive behavior theory and treatment of EDs. Baseline assessment also included anthropometry, the global EDE interview, the Beck Depression Inventory, the State-Trait Anxiety Inventory (STAI), the Eating Disorders Inventory-Perfectionism Scale, and the Temperament and Character Inventory. RESULTS Of the patients, 45.5% were classified as compulsive exercisers, the prevalence being highest (80%) in restricting-type anorexia nervosa (AN), lowest in EDs not otherwise specified (31.9%), and intermediate in binge/purging AN (43.3%) and in purging-type bulimia nervosa (39.3%). Compulsive exercising to control shape and weight was independently predicted by the EDE restraint score (odds ratio, 1.32; 95% confidence interval, 1.06-1.64; P = .014) after adjustment for ED; the total amount of exercise was associated with EDE restraint, as well as with the Temperament and Character Inventory reward dependence. At follow-up, an improved EDE global score was predicted by lower baseline values, higher baseline STAI and STAI improvement, and lower amount of exercise in the last 4 weeks. Voluntary treatment discontinuation was not predicted by baseline exercise. DISCUSSION Compulsive exercising to control shape and weight is a behavioral feature of restricting-type AN, associated with restraint and temperament dimensions, with influence on treatment outcome.

Enhanced cognitive behaviour therapy for adults with anorexia nervosa: A UK–Italy study

Anorexia nervosa is difficult to treat and no treatment is supported by robust evidence. As it is uncommon, it has been recommended that new treatments should undergo extensive preliminary testing before being evaluated in randomized controlled trials. The aim of the present study was to establish the immediate and longer-term outcome following “enhanced” cognitive behaviour therapy (CBT-E). Ninety-nine adult patients with marked anorexia nervosa (body mass index ≤ 17.5) were recruited from consecutive referrals to clinics in the UK and Italy. Each was offered 40 sessions of CBT-E over 40 weeks with no concurrent treatment. Sixty-four percent of the patients were able to complete this outpatient treatment and in these patients there was a substantial increase in weight (7.47 kg, SD 4.93) and BMI (2.77, SD 1.81). Eating disorder features also improved markedly. Over the 60-week follow-up period there was little deterioration despite minimal additional treatment. These findings provide strong preliminary support for this use of CBT-E and justify its further evaluation in randomized controlled trials. As CBT-E has already been established as a treatment for bulimia nervosa and eating disorder not otherwise specified, the findings also confirm that CBT-E is transdiagnostic in its scope.

Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: an alternative to family therapy?

A specific form of family therapy (family-based treatment) is the leading treatment for adolescents with anorexia nervosa. As this treatment has certain limitations, alternative approaches are needed. “Enhanced” cognitive behaviour therapy (CBT-E) is a potential candidate given its utility as a treatment for adults with eating disorder psychopathology. The aim of the present study was to establish, in a representative cohort of patients with marked anorexia nervosa, the immediate and longer term outcome following CBT-E. Forty-nine adolescent patients were recruited from consecutive referrals to a community-based eating disorder clinic. Each was offered 40 sessions of CBT-E over 40 weeks from a single therapist. Two-thirds completed the full treatment with no additional input. In these patients there was a substantial increase in weight together with a marked decrease in eating disorder psychopathology. Over the 60-week post-treatment follow-up period there was little change despite minimal subsequent treatment. These findings suggest that CBT-E may prove to be a cost-effective alternative to family-based treatment.

Diet, weight loss, and liver health in nonalcoholic fatty liver disease: Pathophysiology, evidence, and practice

Fatty liver accumulation results from an imbalance between lipid deposition and removal, driven by the hepatic synthesis of triglycerides and de novo lipogenesis. The habitual diet plays a relevant role in the pathogenesis of nonalcoholic fatty liver disease (NAFLD), and both risky (e.g., fructose) and protective foods (Mediterranean diet) have been described, but the contribution of excess calories remains pivotal. Accordingly, weight loss is the most effective way to promote liver fat removal. Several controlled studies have confirmed that an intense approach to lifestyle changes, carried on along the lines of cognitive‐behavior treatment, is able to attain the desired 7%‐10% weight loss, associated with reduced liver fat, nonalcoholic steatohepatitis (NASH) remission, and also reduction of fibrosis. Even larger effects are reported after bariatric surgery‐induced weight loss in NAFLD, where 80% of subjects achieve NASH resolution at 1‐year follow‐up. These results provide solid data to evaluate the safety and effectiveness of the pharmacological treatment of NASH. The battle against metabolic diseases, largely fueled by increased liver fat, needs a comprehensive approach to be successful in an obesiogenic environment. In this review, we will discuss the role of hepatic lipid metabolism, genetic background, diet, and physical activity on fatty liver. They are the basis for a lifestyle approach to NAFLD treatment. (Hepatology 2016;63:2032‐2043)

Cognitive-behavioral strategies to increase the adherence to exercise in the management of obesity.

Physical activity plays a major role in the development and management of obesity. High levels of physical activity provide an advantage in maintaining energy balance at a healthy weight, but the amount of exercise needed to produce weight loss and weight loss maintenance may be difficult to achieve in obese subjects. Barriers to physical activity may hardly be overcome in individual cases, and group support may make the difference. The key role of cognitive processes in the failure/success of weight management suggests that new cognitive procedures and strategies should be included in the traditional behavioral treatment of obesity, in order to help patients build a mindset of long-term weight control. We reviewed the role of physical activity in the management of obesity, and the principal cognitive-behavioral strategies to increase adherence to exercise. Also in this area, we need to move from the traditional prescriptive approach towards a multidisciplinary intervention.

Gastric emptying in patients with restricting and binge/purging subtypes of anorexia nervosa.

OBJECTIVES:Gastrointestinal symptoms are common in anorexia and in bulimia nervosa, but their relationship with gastric dysmotility and their possible improvement with refeeding are still debated.METHODS:Twenty-three anorexic patients (12 with the binge/purging and 11 with the restricting subtypes) were studied using an ultrasonographic gastric-emptying test, psychopathological questionnaires, and bowel symptom questionnaires, before and after 4 and 22 wk rehabilitation.RESULTS:Gastric symptom scores were markedly higher in patients than in controls and improved significantly with treatment. On entry, compared to controls, gastric emptying was significantly delayed in restricters and purgers (357 ± 25.3 and 360 ± 13.0 min, respectively, mean ± SEM; controls 207 ± 9.1). After 4 and 22 wk of treatment, it improved in restricters (315 ± 20.1 and 296 ± 17.2 min, respectively), but not in purgers (337 ± 14.3 and 335 ± 15.9 min). No relationship was found between entry values of symptoms of gastric emptying and of psychopathological tests or between their variations over time.CONCLUSIONS:Gastric emptying derangement and dyspeptic symptoms are present in both subtypes of anorexia nervosa patients. Long-term rehabilitation improves gastrointestinal symptoms, gastric emptying, and psychopathological distress in an independent manner, whereas short-term refeeding does not.

Psychological variables associated with weight loss in obese patients seeking treatment at medical centers.

BACKGROUND The identification of process and treatment variables associated with successful weight loss could be a pivotal strategy to reduce attrition and improve effectiveness of dietary treatment in obesity and could help find new therapeutic strategies. OBJECTIVE The aim of study is to identify the psychological predictors of weight loss in patients with obesity compliant to continuous treatment at medical centers. DESIGN Longitudinal observation of a large cohort of obese subjects entering weight-loss programs in the years 2000-2002. SUBJECTS/SETTING Five hundred obese patients who completed 12-month weight-loss treatment by Italian medical centers offering different programs (78.8% females; age 46.2+/-10.8 years; body mass index [BMI; calculated as kg/m(2)] 37.3+/-5.6). MAIN OUTCOME MEASURED Measurements were obtained at baseline and after a 12-month weight-loss program. Psychological distress, binge eating, body uneasiness, and attitude toward eating were evaluated by self-administered questionnaires (Symptom Check List-90, Binge Eating Scale, Body Uneasiness Test, and Eating Inventory [Dietary Restraint, Disinhibition, and Hunger]), together with BMI changes. Weight-loss expectations and primary motivation for seeking treatment (health or improving appearance) were also recorded. RESULTS At follow-up, mean percent weight loss was similar in males and females. Both hierarchical regression and logistic regression analysis revealed that increased dietary restraint and decreased disinhibition were the only independent psychological predictors of BMI change after controlling for age, sex, and baseline BMI (5% weight loss at 12 months: Eating Inventory Restraint (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 1.09 to 1.21) and Disinhibition (OR: 0.92; 95% CI: 0.85 to 0.99); 10% weight loss: Restraint (OR: 1.11; 95% CI: 1.06 to 1.16) and Disinhibition (OR: 0.91; 95% CI: 0.85 to 0.98). Adjustment for centers did not change the results. CONCLUSION Successful weight loss was associated with increased dietary restraint and reduced disinhibition in obese patients seeking weight-loss treatment in several medical centers throughout Italy.

Middle School Primary Prevention Program for Eating Disorders: A Controlled Study with a Twelve-Month Follow-Up

The aim of this pilot study was to evaluate the efficacy of a new school-based eating disorder prevention program designed to reduce dietary restraint and the level of preoccupation with regard to shape and weight. One hundred and six (61 females and 45 males) 11 to 12-year-old students were evaluated, 55 of whom participated in the program (experimental group). An additional 51 students formed the control group. The program met for six sessions, two hours per session. After six months, the experimental group received two booster sessions of two hours in two consecutive weeks. Outcome measures included the Eating Disorder ExaminationQuestionnaire (EDE-Q), the childrens version of the Eating Attitudes Test (EAT), the Rosenberg Self-Esteem Scale (RSES), and a Knowledge Questionnaire (KQ) devised by the authors of the program. The questionnaires were administered in both the experimental and control groups, one week before the intervention, one week afterwards, and at six-month and 12-month follow-ups. Unlike a previous school-based eating disorder prevention program, in the experimental group both an increase in knowledge and a decrease in some attitudes were maintained at 12-month follow-up (Eating Concerns EDE-Q scores). Although more intensive interventions seem necessary to modify shape and weight concern and self-esteem, these findings suggest that the intervention had been useful since it led to both an increase in knowledge and a decrease in some dysfunctional eating attitudes.

Stage of change and motivation to healthier lifestyle in non-alcoholic fatty liver disease

BACKGROUNDS & AIMS Healthy diet and physical activity are the treatment cornerstones of non-alcoholic fatty liver disease (NAFLD); their effectiveness is however limited by difficulties in implementing lifestyle changes. We aimed at determining the stage of change and associated psychological factors as a prerequisite to refine strategies to implement behavior changes. METHODS We studied 138 consecutive NAFLD patients (73% male, age 19-73 years). The diagnosis was confirmed by liver biopsy in 64 cases (steatohepatitis, 47%). All cases completed the validated EMME-3 questionnaire, consisting of two parallel sets of instruments (for diet and physical activity, respectively) and providing stages of change according to transtheoretical model. Logistic regression analysis was used to identify factors associated with stages making behavioral changes more demanding. RESULTS The individual profiles were variable; for diet, no cases had precontemplation as prevalent stage of change (highest score in individual profiles); 36% had contemplation. For physical activity, 50% were classified in either precontemplation or contemplation. Minor differences were recorded in relation to associated metabolic complications or steatohepatitis. Logistic regression identified male sex (odds ratio, 4.51; 95% confidence interval, 1.69-12.08) and age (1.70; 1.20-2.43 per decade) as the independent parameters predicting precontemplation or contemplation for diet. No predictors were identified for physical activity. CONCLUSIONS NAFLD cases have scarce readiness to lifestyle changes, particularly with regard to physical activity. Defining stages of change and motivation offers the opportunity to improve clinical care of NAFLD people through individual programs exploiting the powerful potential of behavioral counseling, an issue to be tested in longitudinal studies.