Behaviour Change

New study uncovers brain circuit responsible for balancing hunger and pleasure-driven eating

Humans eat for two primary reasons: to satisfy hunger and for the pleasure derived from food, even when they are not hungry. While hunger-driven eating is essential for survival, pleasure-driven consumption can accelerate the onset of obesity and related metabolic disorders. A groundbreaking study published in Nature Metabolism has identified specific neural circuits in the mouse brain that promote hunger-driven feeding while suppressing pleasure-driven eating. These findings offer promising avenues for developing new strategies to combat obesity.

“Ideal feeding habits would balance eating for necessity and for pleasure, minimising the latter. In this study, we identified a group of neurons that regulate balanced feeding in the brain,” stated Dr. Yong Xu, co-corresponding author, professor of paediatrics – nutrition, and associate director for basic sciences at the USDA/ARS Children’s Nutrition Research Center, Baylor College of Medicine.

Previous research has highlighted the role of neurons marked by the GABAergic proenkephalin (Penk) marker, an endogenous opioid hormone, in regulating feeding and body weight balance. However, their specific role in differentiating hunger-driven and pleasure-driven feeding had not been fully understood.

In this study, Xu and his colleagues demonstrated that activating Penk neurons in a brain region called the diagonal band of Broca (DBB) in male mice promotes an ideal feeding pattern, increasing hunger-driven feeding while reducing pleasure-driven eating.

“I was surprised by this finding,” Xu remarked. “We and other groups had previously shown that certain groups of neurons affect both feeding types in the same way – they either increase or decrease both types. Here, we found that activating DBB-Penk neurons has opposite effects on the two types of feeding; they increase hunger-driven feeding while decreasing eating for pleasure.”

The researchers delved into the mechanisms behind these opposite effects. They discovered that DBB-Penk neurons project into two different brain areas, each regulating a distinct type of feeding behaviour.

“A subset of DBB-Penk neurons that projects to the paraventricular nucleus of the hypothalamus is preferentially activated upon food presentation during fasting periods, facilitating hunger-driven feeding,” Xu explained. “On the other hand, a separate subset of DBB-Penk neurons that projects to a different brain region, the lateral hypothalamus, is preferentially activated when detecting high-fat, high-sugar (HFHS) foods and inhibits their consumption. This is the first study to show a neural circuit that is activated by a reward, HFHS, but leads to terminating instead of continuing the pleasurable activity.”

Remarkably, mice in which the entire DBB-Penk population had been eliminated showed a significant behavioural change. When given a choice between chow and HFHS diets, these mice reduced their consumption of chow but increased their intake of HFHS foods, leading to rapid development of obesity and metabolic disturbances.

“Our findings indicate that the development of obesity is associated with impaired function of some of these brain circuits in mice,” Xu noted. “We are interested in further investigating molecular markers within these circuits that could be suitable targets for the treatment of human diseases such as obesity.”

The study’s contributors include Hailan Liu, Yongxiang Li, Meng Yu, Olivia Z. Ginnard, Kristine M. Conde, Mengjie Wang, Xing Fang, Hesong Liu, Longlong Tu, Na Yin, Jonathan C. Bean, Junying Han, Yongjie Yang, Qingchun Tong, Benjamin R. Arenkiel, Chunmei Wang, and co-corresponding author Yang He, affiliated with institutions such as Baylor College of Medicine, Baylor’s USDA/ARS Children’s Nutrition Research Center, Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, and the University of Texas Health Science Center at Houston.

US panel advises intensive behavioural counselling for children with obesity

A panel of experts in the United States has revised its guidance for paediatric obesity screening, with new recommendations highlighting the necessity for intensive behavioural interventions for children over the age of six who have a high body mass index (BMI). This update, issued by the U.S. Preventive Services Task Force, was published in the Journal of the American Medical Association (JAMA) Tuesday, 18th of June, 2024.

Replacing their 2017 advice, the Task Force previously suggested that primary care providers merely screen children for obesity. The urgency of the update is underscored by data showing that nearly 20% of U.S. children are classified as having obesity, a condition defined as having a BMI at or above the 95th percentile for a child’s age and sex. The prevalence of obesity is notably higher among Latino, Native American, and Black children, as well as those from lower-income backgrounds.

Dr. Wanda Nicholson, Chair of the Task Force and a professor of prevention and community health at George Washington University, emphasised the complexity of factors contributing to childhood obesity but pointed to strong evidence supporting intensive counselling. “Fortunately, we know that there are proven ways that primary care clinicians can help many children and teens to address the high BMI,” Dr. Nicholson stated. She highlighted that “Our evidence shows that the behavioural counselling intervention of 26 or more hours can help them achieve a healthy weight and improve their quality of life.”

Notably, the new recommendations do not advocate for the prescription of weight-loss drugs such as Ozempic or other GLP-1 medications for children, citing insufficient research on the benefits and potential harms of such treatments in younger populations. “We’re calling for more research into both the benefits and potential harms of medication therapy for kids and teens,” Dr. Nicholson explained.

The advised behavioural interventions typically encompass three core elements: education on healthy eating habits, counselling on weight-related behavioural changes—including goal-setting—and supervised exercise sessions.

The Task Force has awarded these recommendations a ‘B’ grade, reflecting a high degree of confidence in the moderate benefits of the interventions. Importantly, this grade also mandates that the recommended services be covered by most private health insurance plans in the U.S. without a copayment, as per federal law.

Despite the clear benefits, Dr. Nicholson acknowledged the challenges these recommendations might pose for affected families. “Twenty-six hours of counselling is a commitment both by the child or teen and their parents,” she remarked, noting that obstacles such as finding a provider who offers intensive counselling or reliable transportation to sessions could limit access to these essential services.

Dr. Nicholson expressed optimism about the potential outcomes of these investments in health. She mentioned that most of the research reviewed by the Task Force spanned six to twelve months of counselling, but stressed the need for further studies to explore the impacts of longer-term counselling initiatives.

Research shows effective parental approaches to managing children’s avid eating behaviours

A recent study, published in the journal Appetite, provides an in-depth exploration of how parents cope with their preschool-aged children’s intense eating behaviours, which are often characterised by an elevated responsiveness to food cues. These eating patterns are closely associated with risks of overweight and obesity in children, making the understanding of parental experiences and strategies essential for developing tailored interventions aimed at promoting healthy eating habits.

The research highlights the significance of recognising eating behavioural patterns in children rather than focusing solely on individual eating behaviours. Through the use of Latent Profile Analysis, researchers have identified various eating profiles among preschoolers. These profiles are typically marked by a pronounced enjoyment of food, emotional overeating, minimal fussiness, reduced sensitivity to satiety signals, and a rapid pace of eating. Genetic factors play a substantial role in these appetitive traits, which are also influenced by environmental interactions, thereby affecting the expression of eating behaviours and the potential for obesity.

Parental feeding practices are pivotal in shaping these behaviours, with key practices involving coercive control, structured feeding, and the support of child autonomy. Qualitative research underscores the challenges parents face in managing feeding interactions, especially with children prone to obesity.

The study forms part of the “Appetite in Preschoolers: Producing Evidence for Tailoring Interventions Effectively” (APPETItE) programme. It adheres to pre-registration and qualitative research reporting guidelines, involving parents of 3-5-year-old children who exhibit these intense eating behaviours. A group of 15 parents participated, providing valuable insights through interviews conducted via video calls. Data collected included demographics, food security, and detailed eating behaviour profiles.

Thematic analysis was employed to inductively scrutinise the interview transcripts, with a focus on parental experiences. This process was rigorous, involving regular discussions and maintained reflexivity to ensure integrity in the analysis. The approach followed the systematic six-step process outlined by Braun and Clarke, fostering a comprehensive understanding of the feeding practices applicable to children with intense eating behaviours.

Four primary themes emerged from the analysis:

1. Persistent Hunger: Parents noted their children’s continuous requests for food, with some perceiving this as a natural trait, while others expressed concern. Despite frequent eating, the level of satiety control varied among children, with some lacking a clear ‘stop button’.
2. Duty of Parenthood: Parents expressed a strong sense of responsibility to keep their children sufficiently fed and to limit exposure to unhealthy foods. They employed various strategies to regulate food intake, focusing on health implications and setting boundaries.
3. Instilling Healthy Habits: There was a concerted effort by parents to foster healthy lifelong eating patterns, provide balanced diets, and educate children on the impact of food on health. Monitoring of food intake throughout the day was common, alongside promoting healthier alternatives and encouraging children’s autonomy in food choices.
4. Navigational Strategies: Parents described ‘picking their battles’ by establishing clear rules for eating times and occasionally using coercive feeding practices to alleviate personal stress. They balanced routine with flexibility, sometimes allowing children autonomy in food choices.
   

The research highlights the effectiveness of an authoritative feeding approach that blends control with warmth and responsiveness. However, some parents also resorted to emotional feeding and the use of food as a reward, which could reinforce intense eating behaviours.

Despite providing rich qualitative insights, the study’s findings are limited by a lack of diversity in the sample and potential self-selection bias, which may affect the generalisability of the results. Future research should incorporate objective measures, such as body mass index, to enhance understanding.

In conclusion, this study illuminates the complex dynamics of feeding children with intense eating behaviours and advocates for responsive, nuanced approaches to foster healthy dietary habits.

NICE approves digital health therapies for psychosis treatment in the NHS

The National Institute for Health and Care Excellence (NICE) has officially approved three innovative digital therapies for incorporation into the treatment of psychosis within the NHS, pending further investigation into their benefits. This provisional approval, part of an early value assessment, encompasses AVATAR Therapy, SlowMo, and CareLoop, each targeting different aspects of psychosis management.

AVATAR Therapy utilises sophisticated software to create a digital representation or avatar of the distressing voices often heard by individuals suffering from psychosis. This digital approach involves patients in therapeutic dialogues spanning six to twelve sessions, wherein a mental health professional animates the avatar. This interaction is designed to facilitate a tripartite conversation, aiming to reduce the impact of auditory hallucinations.

SlowMo, on the other hand, emerges from a collaboration between the Psychosis Research Partnership at King’s College London and the Helen Hamlyn Centre for Design at the Royal College of Art. This therapy employs a web application linked to a smart device to help individuals recognise and moderate the rapid thought processes associated with psychosis, particularly paranoia. By slowing down these thoughts, the therapy aims to lessen the distress they cause.

The third therapy, CareLoop, is an application focused on preventing relapses. It enables patients to document their symptoms, thoughts, and feelings through a journaling feature and structured questionnaires. An underlying algorithm analyses these entries to detect early signs of potential relapse, allowing healthcare teams to intervene promptly.

These three digital health technologies are now available for use within NHS care teams on the condition that they actively collect and share data on their effectiveness over a three-year period, providing annual reports to NICE.

Furthermore, a separate assessment by NICE has recognised the potential of gameChangeVR, a virtual reality technology, for treating severe agoraphobic avoidance in individuals with psychosis, marking another step forward in digital health solutions for mental health.

NICE’s reports underline several advantages these digital therapies may offer, including improved accessibility to mental health services—which are currently under high demand and unevenly distributed across the NHS. These technologies not only provide an alternative treatment option for those unable to access traditional psychological interventions but also require no specialised training in cognitive behavioural therapy for psychosis (CBTp), potentially broadening the pool of mental health professionals who can deliver these services. Additionally, when integrated with standard care, these digital solutions could decrease the frequency of therapy sessions needed.

Earlier in the year, NICE also supported the use of Brainomix’s stroke management software, further demonstrating its commitment to integrating digital health technologies into healthcare provision.

New machine learning approach transforms behavioural health medication practices

At the recent AMCP Nexus 2023 conference in Orlando, Florida (16th-19th of October), presenters showcased a groundbreaking machine learning program designed to address medication-related issues in individuals with behavioural health conditions. This program has shown promising results in reducing polypharmacy, enhancing medication adherence, and decreasing healthcare costs.

Behavioural health conditions pose a significant challenge to healthcare systems. A 2020 Milliman study examining commercial healthcare claims data from 2017, which encompassed 21 million people, revealed that although only 27% had a behavioural health condition, they accounted for over half of the total healthcare expenditures. In this context, machine learning offers a potential solution for better managing these conditions.

The presenters highlighted the issue of polypharmacy, a common concern in behavioural health where 60% of adults with a condition are prescribed two or more psychotropic medications. Polypharmacy not only increases the risk of drug interactions and adverse events but also contributes to soaring healthcare costs. Dr. Caroline Carney, Chief Medical Officer at Magellan Health, underscored the tendency for medication overlap and overprescription in treating conditions like depression and anxiety, often leading to unnecessary medication layers.

Another issue in managing behavioural health medications is the multiple prescribers involved, including primary care doctors, specialists, and inpatient clinicians, often resulting in uncoordinated treatment. This lack of coordination can leave patients confused and overwhelmed with their medication regimens.

To combat these challenges, Magellan Health collaborated with Arine, a medication management tech startup, to create inforMED (formerly known as Navigate Whole Health). This AI-driven program identifies prescribers who can potentially optimise patient care, generating comprehensive care plans with treatment recommendations and patient education. The program’s effectiveness is continuously improved by incorporating new clinical outcome data.

Dr. Carney elaborated on the program’s approach, which considers hundreds of parameters, providing prescribers not just with medication change suggestions but also with reasons, implications, and evidence-based support for the recommended changes.

Yoona Kim, PharmD, PhD, co-founder and CEO of Arine, explained that machine learning algorithms are utilised to target prescribers based on their prescribing patterns and the presence of prescribing outliers in their patient panels. The program also considers social determinants of health, using ZIP code data to assess potential barriers to healthcare access, such as low income or lack of vehicle access.

The results of this program have been significant. Dr. Kim reported a reduction in behavioural health polypharmacy by 45% to 55%, a 20% increase in medication adherence, a 20% reduction in average daily morphine milligram equivalents, and a savings of $360 to $840 in pharmaceutical costs per enrolled member annually.

Dr. Carney emphasised the program’s success in providing actionable data and guidance to healthcare providers, leading to improved patient outcomes and stronger, longer-lasting professional relationships. This innovative approach signifies a major step forward in the management of medication for behavioural health conditions.

US panel of health experts advocate early interventions for childhood obesity from age 6

A panel of U.S. health experts has put forth a draft recommendation advocating for children with obesity to begin receiving comprehensive counselling aimed at fostering healthy eating and exercise habits, starting at the age of 6. This guidance, issued by the U.S. Preventive Services Task Force (USPSTF), builds upon their 2017 recommendation which suggested that obesity screening should commence from the same age.

Recent research underscores the value of intensive behavioural interventions, defined as a minimum of 26 hours of counselling with one or more health professionals, in aiding children and adolescents to achieve and maintain a healthy weight and enhance their overall quality of life. However, the recommendation does not set a specific timeframe for these interventions.

The USPSTF’s updated advice does not delve into the use of weight-loss medications like Novo Nordisk’s Wegovy, approved for use in children aged 12 and above, nor does it address surgical options. The Task Force reviewed evidence surrounding weight-loss medications but noted that further research is needed to fully grasp the long-term health impacts of such treatments.

According to Dr. Katrina Donahue from the University of North Carolina School of Medicine and a member of the Task Force, the proposed behavioural interventions encompass a combination of physical activity, behaviour change support, and education on healthy eating. Recognising that available resources vary by location, Donahue acknowledged that the implementation of these interventions might differ across cities.

The recommendation is backed by data from 58 randomised controlled trials involving over 10,000 children, which demonstrated the effectiveness of these interventions when a child engages in at least 26 hours of professional contact. The evidence for these intensive interventions received a “grade B” from the USPSTF, indicating high certainty of at least moderate benefit. The children in these trials lost an average of 4 to 6.5 pounds (approximately 2 to 3 kilograms), with the reductions being sustained for at least a year.

Childhood and adolescent obesity, through the age of 19, is defined as having a body mass index (BMI) – a weight-to-height ratio – higher than that of 95% of peers of the same age and gender. Nearly one in five U.S. children and teenagers are categorised as having obesity, based on data from the U.S. Centers for Disease Control and Prevention (CDC).

The American Academy of Pediatrics (AAP) guidelines also endorse lifestyle support, including over 26 hours of face-to-face, family-based, multicomponent treatment spanning 3 to 12 months. Additionally, the AAP recommends paediatricians consider weight-loss drugs for children with obesity aged 12 and over and to refer adolescents aged 13 and older with severe obesity for metabolic and bariatric surgery evaluation.

The USPSTF’s draft recommendation is open for public comment until the 16th of January 2023, inviting a wider discourse on the proposed approach to tackle childhood obesity.

Oxford study shows doctors’ communication style crucial for patient weight loss success

A groundbreaking study from the University of Oxford, recently published in the Annals of Internal Medicine, has revealed that the manner in which doctors communicate with patients about obesity plays a pivotal role in their weight loss success. This innovative research delves into the nuances of communication, showing that not only do the words doctors use matter, but also their tone and delivery have a profound impact over both short and long-term patient outcomes in a medical setting.

Conducted by the Nuffield Department of Primary Care Health Sciences, the study analysed 246 recordings of consultations and discovered that even subtle elements like the choice of words and vocal tone significantly affect patient responses. The findings have emerged amidst obesity treatment guidelines urging doctors to initiate weight loss discussions and suggest weight loss services. However, effective communication on this front occurs for only about 5% of those affected annually, indicating a significant gap between policy and practice.

Many doctors express reluctance to broach sensitive topics like obesity due to fears of offending patients or feeling uncertain about handling such discussions. From the patients’ perspective, negative experiences stemming from certain tones or word choices can inadvertently harm the doctor-patient relationship.

This research, funded by the National Institute for Health and Care Research School for Primary Care Research and Foundation for the Sociology of Health and Illness, utilised conversation analysis techniques on audio recordings from the BWel trial. In this trial, doctors offered patients referrals to a 12-week weight loss programme, and the researchers observed how different communicative approaches – categorised as ‘good news’, ‘bad news’, or neutral – influenced patient engagement and satisfaction.

Statistical analysis revealed that patients were more likely to enrol in, attend, and lose more weight in programmes when the referral was framed as ‘good news’. Specifically, 83% of patients offered programmes in a positive light attended, compared to only 50% for neutrally framed offers. Those who received ‘good news’ also lost about half a stone (3.6kg) more compared to the ‘neutral’ or ‘bad’ news groups.

Dr Charlotte Albury, the study’s lead author, emphasised that framing weight loss conversations positively encourages patients to participate more actively in programmes, yielding better weight loss outcomes. She noted that while both ‘neutral’ and ‘negative’ framings led to similar levels of programme acceptance and weight loss, the ‘good news’ approach stood out for its effectiveness.

The study identified specific characteristics of ‘good’ and ‘bad’ news delivery. In the ‘good news’ approach, doctors focused on the benefits of weight loss in an optimistic manner, confidently shared advantages, and communicated fluently and cheerfully. In contrast, the ‘bad news’ framing centred on health issues related to overweight and emphasised patient effort, often marked by slower delivery and hesitations. The neutral approach maintained a steady tone without leaning towards either benefits or issues.

Dr Albury highlighted the importance of these findings for medical professionals, suggesting that adopting a ‘good news’ approach could significantly enhance patient motivation and success in weight management. By transforming discussions into positive and empowering dialogues, doctors can effectively encourage patients to adopt healthier lifestyles.

Can cognitive behavioural therapy (CBT) help with weight loss?

Cognitive behavioural therapy (CBT) is a type of talk therapy that focuses on identifying unhelpful thoughts and behaviours and replacing them with more positive and constructive ones. 

This therapy aims to help people overcome a variety of issues, including anxiety, depression, phobias, substance use disorders, eating disorders, insomnia, relationships, self-esteem, and personality disorders. CBT is not intended to be ongoing, and typically involves regular sessions with a therapist for anywhere from 4 to more than 20 sessions, depending on the issue being addressed.

CBT can be particularly helpful for people who struggle with weight management, as it focuses on changing the behavioural patterns that contribute to weight gain. For example, if someone tends to overeat in response to stress, CBT can help them develop more positive coping strategies to manage their stress. CBT is also considered a preferred treatment for obesity and binge-eating disorder (BED).

To use CBT for weight loss, a therapist will help an individual set specific and attainable goals, such as reaching a target weight range or adopting a healthier lifestyle. The therapist will also encourage self-monitoring to help the individual become aware of their eating behaviours and to identify potential setback triggers, such as boredom or stress eating. 

By identifying these triggers early on, the individual can take steps to correct them and avoid undoing their progress. The therapist may also offer feedback and reinforcement to help the individual stay motivated and track their progress. While CBT can be a highly effective way to change habits and patterns of thinking, it’s important to remember that lifestyle and behavioural training can take time, and progress may not happen overnight.

Positive parenting can reduce the risk that children develop obesity

Children with positive, early interactions with their caregivers — characterised by warmth, responsiveness, and a stimulating home environment — were at reduced risk of childhood obesity according to new research from Pennsylvania State University in the United States. 

​​The study, “Family Psychosocial Assets, Child Behavioral Regulation, and Obesity,” appeared in the journal Pediatrics. In the article, Brandi Rollins, assistant research professor of biobehavioural health and Lori Francis, associate professor of biobehavioural health, analysed data from over 1,000 mother-child pairs and found that children’s early exposures to family psychosocial assets — including a quality home environment, emotional warmth from the mother, and a child’s ability to self-regulate — reduced the risk of developing childhood obesity.  

“A lot of the discussion around childhood obesity and other health risks focuses on identifying and studying the exposure to risk,” said Rollins, “We took a strength-based approach in our analysis. We found that a supportive family and environment early in a child’s life may outweigh some of the cumulative risk factors that children can face.” 

An especially encouraging aspect of the study found that these factors were protective even when children faced familial risks for obesity, including poverty, maternal depression, or residence in a single-parent home.   

“Research on parenting has shown that these types of family assets influence children’s behaviour, academic success, career, and — not surprisingly — health,” Rollins said. “It is significant that these factors also protect against childhood obesity because the family assets we studied are not food or diet-specific at all. It is heartening to know that, by providing a loving, safe environment, we can reduce the risk that children will develop obesity.” 

Children are deemed to have obesity when their body mass indices (BMIs) are greater than 95% of other children their age and gender. There is a great deal of variance, however, in the BMIs of children who exceed the obesity threshold. Children whose BMI is 20% higher than the obesity threshold are considered to have severe obesity.  

The researchers found that children who had early-onset severe obesity did not face greater levels of family risk than children who were not obese. Children with severe obesity, however, did have fewer family assets than children who were not obese or who displayed moderate levels of obesity. More research is needed to understand which factors contribute to the development of severe obesity and which factors reduce the risk.  

“Though the findings on severe obesity may seem discouraging, they offer some hope,” Rollins explained. “Some risk factors, like household poverty, can be very difficult to change. Assets, on the other hand, may be easier to build. People can learn to parent responsively. It is encouraging that parenting really matters, that family matters.”