1. Biological Aspects of Obesity-Related Eating Disorders: Binge Eating Disorder and the Night Eating Syndrome Allan Geliebter New York Obesity Research Center St. Luke's and Roosevelt Hospitals Columbia University Division of Child and Adolescent Psychiatry Grand Rounds Columbia University February 17, 2010

2. Obesity NIGHT EATING SYNDROME BINGE EATING DISORDER

3. Marx J. Science, 2003; 299: 846-849.

4. Controls of Food Intake Signals Initiation Termination Differences in BED?

5. Main Criteria for Binge Eating Disorder (BED) Recurrent episodes of binge eating 2 days/wk for 6 mos. objectively large amount of food in a discrete time period (2 hours) sense of loss of control without purging afterwards

7. Gut peptides (leptin, CCK, ghrelin)

9. Stomach capacity could limit meal intake and influence satiation. Stomach

10. Gastric Capacity Estimated by filling a intragastric balloon with water at 100 ml/min through a tube connected to a pump behind the person based on maximum volume tolerated based on volume required to produce a fixed rise in intragastricpressure.

11. Table 1. Characteristics of Overweight Women (M ± SD) No differences by group. BODPOD Geliebter A, Gluck ME, Hashim SA. J Nutr 2005;135:1326-30.

12. *

13. *

14. The two estimates of gastric capacity correlated (r = .60, p = .001) with each other.

15. Test Meal Participants ingested a liquid meal through a straw from a large opaque cooler to prevent visual feedback until extremely full.

17. Test meal intake correlated significantly (r = .42, p = .03) with gastric capacity.

20. Gut peptides (leptin, CCK, ghrelin)

23. Ghrelin is elevated before meals and falls afterwards (Cummings et al, 2002), unlike other peripheral appetite hormones, which rise after meals. Hypothesis Obese individuals with BED would have high ghrelin levels given their excess meal intake.

25. Meal was provided at time 0 and consumed at constant rate from graduated beaker in 5 min.

27. meal

28. meal

29. meal

30. Ghrelin Findings BED S’s had lower fasting ghrelin levels than non-BED S’s, contrary to hypothesis. In BED S’s, ghrelin levels declined less after meal. Results extend and are consistent with findings of lower ghrelin levels in obese individuals. Ghrelin may be down-regulated in obese BED S’s due to overeating possibly via stomach capacity. Geliebter A, Gluck ME, Hashim SA. J Nutr 2005;135:1326-30

32. Gut peptides (leptin, CCK, ghrelin)

34. Participants Women (n = 20) Geliebter A, Logan M, Ladell T, Schneider T, Sharafi M, Hirsh J. Appetite 2006;46:31-5

36. Visual Runs Stimulation Baseline Baseline Binge Non-binge Non-foods

37. Auditory Runs Stimulation Baseline Baseline Binge Chocolate Cookies Caramel Sundae Pepperoni Pizza Acorn Squash Iceberg Lettuce English Cucumbers Non-binge Looseleaf Binder Pencil Sharpener Letter Opener Non-food

38. Individual Analysis (Method 1) The analysis used an fMRI program, which identifies brain activation areas for each individual.

39. Obese NonBinge Eater Obese Binge Eater L R Lean Binge Eater Lean NonBinge Eater

41. For 80%, it was in the oral premotor region.

42. It is unlikely that this was due to swallowing as the primary motor area was not activated.

44. Controls of Food Intake Signals Stomach PeptidesStress Hormone Initiation Ghrelin Cortisol TerminationCapacity CCK, Leptin Emptying Differences found in BED

45. Night Eating Syndrome (NES) NES was first described by Stunkard(Stunkard, 1955)

47. Psychological factors

48. Stress

49. Sleep Timing

50. Treatment

52. NES Prevalence

53. NSRED NES - + Conscious during eating + - Amnesia after eating + - Associated parasomnias + - Consumption of non-food - + Depressed mood - + Evening hyperphagia Rare Moderate Prevalence Night Eating Syndrome vs. Nocturnal Sleep-Related Eating Disorder

55. Psychological factors

56. Stress

57. Sleep Timing

58. Treatment

61. weekly nutritional counseling sessions

63. NES Normal 50 45 40 p = .005 35 p = .06 30 25 20 15 10 5 0 Hunger Fullness

67. Psychological factors

68. Stress

69. Sleep Timing

70. Treatment

72. NES often remits if stress alleviated (Stunkard, 2002)

73. Progressive muscle relaxation improves symptoms of NES (Pawlow et al, 2003)(Allison & Stunkard, 2004)

80. Measured basal plasma cortisol at 8:30 am

81. Measured plasma cortisol at 8:30 am in response to dexamethasone the night before

83. Basal Cortisol ns g/dL

84. Cortisol Following DST n.s. g/dl

85. Cold Pressor Test HAND IMMERSION HAND WITHDRAWAL I I I I I I I 0 2 15 5 30 60 45 -10 min Blood Draws for Cortisol, Ghrelin, Hunger Ratings

86. Cortisol g/dL Main effect, p<.05 Group diff , n.s. Baseline (mean of -10 and 0 min) NE > Norm, p<.05 AUC, NE > Norm,p=.02, (n.s. after controlling for baseline.)

87. Ghrelin pg/mL Main effect, p<.05 Group diff , n.s. Baseline (mean of -10 and 0 min), n.s. AUC, n.s.

88. Hunger Main effect, p<.05 Group diff, n.s. Baseline, n.s. AUC, n.s.

89. Controls of Food Intake Signals Stress HormoneTime Cues Initiation Cortisol Evening/Night Termination Differences found in NES

91. Psychological factors

92. Stress

93. Sleep Timing

94. Treatment

96. Food Intake NES > Controls Inpatient study reflects night eating (20 h- 08 h) in NES subjects (Allison et al,. 2005) Outpatient study shows shifted calorie intake curve in NES (O’Reardon et al., 2004)

98. Psychological factors

99. Stress

100. Sleep Timing

101. Treatment

103. Night Eating Symptom Scale

104. Nocturnal ingestions/week

105. % Caloric Intake after Dinner

106. Weight change

110. Keep tempting foods out of reach

111. Increase breakfast consumptionRecommended Manual Overcoming Night Eating Syndrome Kelly Allison, Albert Stunkard, Sarah Tier New Harbinger, 2004

113. Psychological factors

114. Stress

115. Sleep Timing

116. Treatment

118. Acknowledgements Co-Investigators Marci Gluck, Sami Hashim, Eric Yahav, Dennis Gage, Joy Hirsch, Susan Carnell Resources NY Obesity Research Center provided hormone assays and body composition measurements Grant Support NIH Grants RO1 DK 554318, R01 DK074046, R03 DK068392, and MO1 RR0064529