Patients Can Be Trained to Curb Food Cravings, Seek Better Food Choices

Learning cognitive strategies in brief sessions showed potential to decrease cravings for unhealthy foods, prompt better food choices in people with elevated BMI.

With Hedy Kober, PhD, John Apolzan, PhD, and Robert F. Kushner, MD

With 70% of people in the US—two out of three—overweight or obese, interventions to help people achieve meaningful weight loss that can be maintained remain elusive but crucial.1 A team of researchers from Yale University reported that training people in cognitive strategies may not only reduce cravings for unhealthy foods but seemed to increase preferences for healthy foods—despite the higher cost of the healthier food choices.2

People can be taught to make the right food choices through behavioral training.

The training interventions also resulted in the added bonus of a lower caloric intake; the results were published online in the Proceedings of the National Academy of Sciences.2 The cognitive coaching worked just as well in participants who were overweight as in those with obesity, said Hedy Kober, PhD, associate professor of psychiatry and psychology at Yale, and lead author of the research.

"From the series of studies, we found that there was no correlation between change in food choice and body mass index (BMI)," said Dr. Kober. "That is, training effects seen in individuals at higher BMI were similar to those in individuals with a lower BMI." For that reason, she told EndocrineWeb, “we the think the training intervention will be equally effective across all obesity subtypes.4

Methodology Tames Cravings with Cognitive Training Techniques  

Dr. Kober's team conducted six studies, involving 1,528 people in all, to develop and trial the intervention aimed to improve eating behaviors by employing a concept termed, Regulation of Craving Training, or ROC-T, which was conducted both online and in the lab.

Applying ROC-T was comprised of two cognitive strategy instructions that framed certain foods as bad or good for the individual.2 Regarding so-called bad foods, participants were instructed to think about the negative aspects of the identified problem foods, such as long-term health consequences. About foods termed “good”, individuals were guided to think about positive qualities, such as health advantages (eg, high fiber, minimally processed, whole grain), or liking the taste.2

The researchers also focused on a willingness to pay, a measure used by economists to predict consumer behavior. For example, would people pick the $2 slice of pizza at the mall over the $10 salad? And would they change their selection once they were exposed to cognitive training about healthy and unhealthy foods?

In the first two studies, the researchers used ROC-T to test the response to cognitive training techniques on decreasing cravings for unhealthy foods and increasing craving for healthy foods.2  They also tested the effect of participants' willingness to pay for healthy versus unhealthy foods.

Dr. Kober and her team validated the effectiveness of the cognitive training in decreasing food cravings for identified, unhealthy food and a growing preference for healthy foods.2 The strategies employed by the trainers appeared to modify the subjective value of food selections as measured by a person’s willingness to spend more money such that the positive characteristics increased reinforced the value of paying for “good” food, and the negative associations led to a decreased desire for both unhealthy and low-cost foods (P < 0.001).2

In studies 3 and 4, a brief training with cognitive strategies was found to repeat the results whereby the selection of healthy food options rose and unhealthy food choices were selected less often.2 In the fifth study, Dr. Kobe said they found that the training actually reduced calories consumed by 93 to 121 calories.2 In the final test, participants were presented with healthy and unhealthy foods in gallon containers.

Foods included baby carrots, candy, potato chips, and apple slices. Participants were invited to eat ad libitum. Of the group, 64 participants, mean age 18 years with a mean BMI of 23 kg/m2, were asked to taste all four foods and then continue to eat as desired, and provide taste ratings.2 The food items were secretly weighed in grams before and after the test, with individual caloric intake estimated. Those who had been exposed to both the negative and positive ROC-T consumed fewer calories than those in the control, opting for less of the unhealthy foods (P = 0.008).2

In the final study arm,2 the researchers compared ROC-T to a framing-only control condition to test that the effect was attributable to the training—and was able to confirm that the cognitive behavioral training was reasonable for the change in food selection,2 Dr. Kober said. Overall, cognitive training changes in food cravings and perceived food value led to improved food choices by 5.4 to 11.2%.2

Brief Cognitive Instruction was Sufficient to Produce Changes in Food Perceptions

"In this series of tests, we were able to show that the effects of a single 20-minute ROC-T session lasted for at least 30-45 minutes," Dr. Kober said, ''as was the duration of the food taste test. Now, we are actively testing whether the effects will last longer than this, and what the effects may be from multiple [cognitive training] sessions."

This work was an extension of similarly devised research with smokers,5 according to Dr. Kober, in which she found that even a single session of cognitive associative training was sufficient to lower rates of smoking for as long as a month.5  Still, she said, ''it is likely that multiple sessions would be most beneficial to achieved long-term [sustained] weight loss."

As for the possible mechanism of action behind these behavior changes, Dr. Kober told EndocrineWeb, "We have previously demonstrated that the strategies employed in ROC-T depended on recruitment of regions of the prefrontal cortex involved in modulating other brain regions that underlie cravings and computed values. As such, we are testing the mechanisms underlying ROC-T directly using functional magnetic resonance imaging to confirm observed behavior changes."

Cognitive Training Offers Promise Yet Requires Replication,  Longer Term Trialing 

Two experts who reviewed the findings for EndocrineWeb viewed the ROC-T technique as interesting and potentially valuable in helping people to manage food cravings to achieve weight control but perhaps the cognitive training is not yet ready for prime time.

"The sequences of studies were well designed and developed to answer specific questions," said Robert Kushner, MD, professor of medicine and director of the Center for Lifestyle Medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois.  

One overriding concern is whether the behavior changes could be retained over time. "All of the studies tested immediate responses to food cravings, so we do not know if the changes will be short-lived and extinguish quickly,'' he said.

Among the other unanswered questions, he pointed out that we would need to know whether the findings would work for patients with type 2 diabetes (T2D). ''However, the authors made a point that the training was meant to be generalized,'' he said.

Dr. Kober acknowledged that they had not asked any of their participants if they had been diagnosed with T2D but due to the large sample size, and the fact that many were obese, ''it is likely that at least some individuals had diabetes, and that the cognitive training worked for them." In future work, she said, it might be possible to tailor the training to be more specific to the needs of those with type 2 diabetes. For example, focusing on high and low glycemic foods or foods with added sugars or unhealthy fats to address the medical complications facing those with or at risk for hyperlipidemia.

Dr. Kushner emphasized that although cognitive behavior therapy (CBT) ''is the cornerstone of behavioral treatment for obesity," he suggests awaiting more data on the longer-term effects from these researchers.

"It is noteworthy that the authors analyzed several of their studies against change in BMI and found that despite higher levels of food cravings for subjects with higher BMI there was no difference in response to ROC-T among the participants," he said. "However, these were well-designed experiments that did not reflect a typical patient population in which there are multiple determinants for obesity and differences in initial eating patterns and foods preferences. Future studies would need to be done in this population in order to determine the utility [of this behavioral technique].''

Similarly guarded optimism was offered by an expert in cravings research. ''The findings are exciting because the suggestion is that acute or short-term cognitive training can have a significant influence on and reduction in food intake for the proposed next meal," said John Apolzan, PhD, assistant professor and director of the Clinical Nutrition Lab, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge. "This is fairly new and novel, Dr. Apolzan told EndocrineWeb,

However, he suggested that a necessary next step should be to examine the effects of the training in a ''real world'' setting such as taking participants to a food court or a buffet to determine how the lab and online research results bear out there.

Definite Advantages to Online Training to Challenge Undesirable Food Cravings As Needed

"ROC-T is now fully computerized with several of the studies described in the paper administered online,” Dr. Kober said, making the training effective across all age groups, including children and teens. "However, thus far, we have only tested ROC-T directly on adults," she said.

As the research unfolds, Dr. Apolzan said, the ROC-T might be incorporated into nutrition sessions given by dietitians or certified diabetes educators (CDE) with physicians referring their overweight and obese patients to a dietitian or CDE versed in the cognitive behavior technique. This may prove a very applicable approach for patients with prediabetes and type 2 diabetes given the demonstrated benefits of virtual coaching.6

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