Behavioural TreatmentFundamentals of Reward Learning

Canadian Obesity Summit 2013

David Macklin MD CCFPDirector, Weight ManagementMedcan Weight Management Program

• Faculty: Dr David A. Macklin MD CCFP• Program: 51st Annual Scientific Assembly

• Relationships with commercial interests:– No Grants/Research Support

– No Speakers Bureau/Honoraria– No Consulting Fees

– Independent Practitioner

Faculty/Presenter DisclosureFaculty/Presenter Disclosure

Disclosure of Commercial SupportDisclosure of Commercial Support

• This program has received no financial support from any organization.

• This program has received no in-kind support from any organization

• Potential for conflict(s) of interest:• None

Disclosure

N/A

Mitigating Potential BiasMitigating Potential Bias

Learning objectives

1. Learn how the collision between the "ancient reward brain" and the pleasures of our modern "hyperpalatable food" environment conditions a motivation to overeat based on Pavlovian associative learning

2. Learn how the behavioural weight management principles of stimulus control, cognitive restructuring and self monitoring can be explained and illuminated in the context of emerging reward theory

Learning objectives

3. Be able to identify critical subconscious elements to overeating such as associative learning, upwards modulation of wanting by negative emotions, physical hunger and priming, and downward modulation by exercise

4. Be able to identify critical conscious elements to overeating such as non-expectancy, false negative thinking, permission thinking and counter dialogue development

Behavioural Treatment Structure

Five modules

1.Conditioned Wanting2.Up-and-down modulation of wanting3.Non-expectancy4.Permission thinking 5.counter dialogue development

Conditioned Wanting

Time

9 P.M.CouchTVcoffee tablesittingend of daydarkoutside

Subconscious Conscious

Permission Thoughts

Wanting

NonExpectancy

Counter Dialogue

VS. Consequences • NegativeE

motions

• Priming

• Exercise

• Hunger

Conscious

The History

In addition to....

1. Weight history2. Past weight loss history3. Past medical history4. Medication history5.Patient and family "Reward" history

Let's get the EATING history...

Mapping

Wake Sleep

Conditioned Wanting

High Risk SettingsA finite list of settings associated with past hyper-palatable food eating and current sensitized wanting

MAJOR MINOR

1. Night Eating 2. Desserter3. Big Dinnerer4. Homecoming King/Queen5. Afternooner6. Big Luncher

1. Weekender2. Socialite3. Restauranteur4. The cats away

Neuro-Behavioural

The Big MismatchAncient brain reward circuit vs. modern-tasty food filled environment.

Hyper-palatable Food

Environment

1. Dramatic proliferation of hyper palatable foods.2. Available everywhere; street corner, coffee shop, vending machine,

restaurant, grocery store.3. Now acceptable to eat anytime anywhere (dissolution of past societal norms).4. Portion sizes exploded.

Conditioned Wanting

Time

9 P.M.CouchTVcoffee tablesittingend of daydarkoutside

Subconscious Conscious

Permission Thoughts

Wanting

NonExpectancy

Counter Dialogue

VS. Consequences • NegativeE

motions

• Priming

• Exercise

• Hunger

Conscious

Modulators of Wanting

Time

9 P.M.CouchTVcoffee tablesittingend of daydarkoutside

Subconscious Conscious

Permission Thoughts

Wanting

NonExpectancy

Counter Dialogue

VS. Consequences • NegativeE

motions

• Priming

• Exercise

• Hunger

Non Expectancy

Time

9 P.M.CouchTVcoffee tablesittingend of daydarkoutside

Subconscious Conscious

Permission Thoughts

Wanting

NonExpectancy

Counter Dialogue

VS. Consequences • NegativeE

motions

• Priming

• Exercise

• Hunger

Permission Thinking

Time

9 P.M.CouchTVcoffee tablesittingend of daydarkoutside

Subconscious Conscious

Permission Thoughts

Wanting

NonExpectancy

Counter Dialogue

VS. Consequences • NegativeE

motions

• Priming

• Exercise

• Hunger

Counter Dialogue Development

Time

9 P.M.CouchTVcoffee tablesittingend of daydarkoutside

Subconscious Conscious

Permission Thoughts

Wanting

NonExpectancy

Counter Dialogue

VS. Consequences • NegativeE

motions

• Priming

• Exercise

• Hunger

Case example

Case example

Patient : Big Dinnerer + Night eating patternTotal energy expenditure 2700 Kcal/day --> cal script 1700

1. Eat 900 cals pre dinner

2. Eat 800 cals for dinner

3. Dinner and done

4. Learn how better you feel

Summary

Applying this framework can result in a lessening of stigma and can provide patient empowerment.

Applying this framework allows for standardization and personalization of treatment, allowing for scale.

Overcoming Overeating

Thank You! Questions?

David Macklin MD CCFP

Director, Weight Management Medcan Weight Management