Appetitive traits as targets for weight loss: The role of food cue responsiveness and satiety responsiveness
Introduction
Obesity is highly prevalent in the United States as approximately one third of children and two thirds of adults have overweight or obesity (OW/OB). [1,2] OW/OB is associated with cardiovascular disease, type 2 diabetes, cancer, osteoarthritis, psychological impairment, poor quality of life and all-cause mortality. [3,4] Medical care for individuals with OB costs nearly $150 billion across the United States, [5] and these costs are expected to rise by $48–66 billion per year by the year 2030. [6] Considering the high prevalence rates, rising medical costs, and significant comorbidities, it is essential that more potent models are developed to treat OW/OB effectively.
The current empirically supported treatment for adults with OW/OB is behavioral weight loss (BWL). [7], [8], [9], [10], [11], [12] BWL includes dietary and caloric recommendations, guidelines for physical activity, and behavior therapy skills to adhere to treatment recommendations. Although BWL is effective and provides clinically significant weight loss for some adults, [10] BWL is not effective for all individuals. Up to 50% of participants in BWL treatment programs fail to achieve meaningful weight loss. [11] Moreover, BWL is even less effective in providing long-term weight-loss maintenance, as 65% of participants no longer meet the initial 7% weight-loss goal 4 years post-treatment. [12] These results could be due to heterogeneity and a lack of consideration for individual characteristics that can impact treatment response. [13,14] Thus, it is imperative to understand the individual characteristics that predict treatment outcomes in the short and long term, and to develop novel treatments to address mechanisms associated with non-response.
Eating past nutritional needs, or overeating, is one of the most proximal drivers of OB rates [15,16] and is considered more important than metabolic changes. [17], [18], [19] Rates of overeating are especially high in OW/OB samples, with up to 80% of adults with OW/OB endorsing overeating regularly. [20] Overeating is a complex process which is influenced by individual behavior, the environment, genes, physiology, and neural processes. However, societal advances have created an “obesogenic” environment that encourages excess energy intake and discourages energy expenditure. [21], [22], [23], [24] Calorically dense foods are easily available, highly variable, tasty, relatively inexpensive, and portable. [25], [26], [27], [28], [29] Overeating in today's environment is incredibly easy, especially for those who have a propensity to overeat.
Section snippets
Behavioral Susceptibility to Overeating
Interestingly, not everyone who lives in this environment has OW/OB. In fact, within the same family there can be weight discordant children. It is possible that some individuals have a behavioral susceptibility to overeat. Behavioral susceptibility was first described by Stanley Schachter who hypothesized that individuals with OW/OB, compared to individuals with a healthy weight, are more reactive to external cues to eat and less sensitive to internal satiety signals. [30,31] Jane Wardle and
Assessments of Food Cue Responsiveness (FR) and Satiety Responsiveness (SR)
A variety of measures exist that assess FR and SR. Jane Wardle and colleagues developed the Child Eating Behavior Questionnaire (CEBQ) [41] several years before the BST was formally articulated. The CEBQ was initially designed to be a parent report of children's eating and includes 8 subscales: FR, SR, emotional over-eating, enjoyment of food, desire to drink, slowness in eating, emotional under-eating and food fussiness. The FR subscale includes four items that assess desires to eat outside of
Development of Food Cue Responsiveness (FR)
Changes in FR over time are considered a product of both genetic and environmental influences. Emerging quantitative genetic modeling suggests that FR may be up to 75% heritable, [77] with the most evidence to date focusing on the “high risk” FTO alleles at rs9939609 in children. [78] Presence of this FTO minor allele at rs9939609 was associated with greater consumption during an EAH task compared with children without any risk allele in multiple samples. [79], [80], [81] As these studies were
Development of Satiety Responsiveness (SR)
Conceptually, individuals will continue to eat in response to conditioned food-related cues until the intake is terminated by interoceptive satiety cues, [97] suggesting that SR is an inhibitory mechanism. SR develops early in life and is also considered to be the result of an interaction of genetic influences and factors in the environment. Several studies suggest that SR could be up to 63–72% heritable. [77,98] Genetic mutations (e.g., in the leptin gene and melanocortin 4 receptor (MC4R)
Relationship Between Appetitive Traits, Eating Behavior, and Body Weight
In both children and adults, studies suggest that FR is associated with greater food consumption, while SR is associated with less food consumption. In children, higher FR was related to faster eating rate and increased energy intake during an EAH paradigm, while higher SR was associated with lower energy intake during the EAH paradigm and lower overall energy intake measured across 5 days. [42] The Gemini Birth Cohort collected data from over 1000 families with children 16 to 21 months old and
Treatment Development of a Program Designed to Target FR and SR
Based on the theory and existing literature, we believe that FR and SR are emerging, important variables related to overeating and OW/OB and could be potential mechanisms for the development of a novel model for weight loss. We developed a treatment program that specifically targets both FR and SR, called Regulation of Cues (ROC). To target improvement in SR, we adapted Appetite Awareness Training (AAT). AAT focuses on rating hunger and satiety and learning to stop eating when physically full
Conclusion
In summary, we believe that FR and SR are important variables related to overeating and weight gain, and it is possible that these two appetitive characteristics may exist along the same continuum. We have outlined the methods for the development of these appetitive traits and how they contribute to overeating in the current food environment. In particular, we have outlined options for intervening with these two mechanisms, by focusing on improving SR by training participants to respond to
Funding
Research reported in this publication was supported by the National Institute Of Diabetes And Digestive and Kidney Diseases of the National Institutes of Health and the Department of Defense under Award Numbers: R01DK103554, R01DK094475, DOD W81XWH-18–1–0220, R01DK114794, K23DK114480. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Department of Defense.
Acknowledgements
This manuscript is based on work presented during the 2019 Annual Meeting of the Society for the Study of Ingestive Behavior, July 9–13, 2019 in Utrecht, Netherlands.
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