1. Behavioural Treatment Fundamentals of Reward Learning Canadian Obesity Summit 2013 David Macklin MD CCFP Director, Weight Management Medcan Weight Management Program

2. Faculty: Dr David A. Macklin MD CCFP Program: 51 st Annual Scientific Assembly Relationships with commercial interests: –No Grants/Research Support –No Speakers Bureau/Honoraria –No Consulting Fees –Independent Practitioner Faculty/Presenter Disclosure

3. Disclosure 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

4. Disclosure N/A Mitigating Potential Bias

8. 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

9. 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

10. Behavioural Treatment Structure Five modules 1.Conditioned Wanting 2.Up-and-down modulation of wanting 3.Non-expectancy 4.Permission thinking 5.counter dialogue development

11. Conditioned Wanting Time 9 P.M. Couch TV coffee table sitting end of day dark outside SubconsciousConscious Permission Thoughts Wanting Non Expectancy Counter Dialogue VS. Consequences NegativeE motions Priming Exercise Hunger Conscious

12. The History In addition to.... 1. Weight history 2. Past weight loss history 3. Past medical history 4. Medication history 5.Patient and family "Reward" history Let's get the EATING history...

13. Mapping WakeSleep

14. Conditioned Wanting High Risk Settings A finite list of settings associated with past hyper-palatable food eating and current sensitized wanting MAJOR MINOR 1.Night Eating 2.Desserter 3.Big Dinnerer 4.Homecoming King/Queen 5.Afternooner 6.Big Luncher 1.Weekender 2.Socialite 3.Restauranteur 4.The cats away

15. Neuro-Behavioural The Big Mismatch Ancient brain reward circuit vs. modern-tasty food filled environment.

16. 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.

17. Conditioned Wanting Time 9 P.M. Couch TV coffee table sitting end of day dark outside SubconsciousConscious Permission Thoughts Wanting Non Expectancy Counter Dialogue VS. Consequences NegativeE motions Priming Exercise Hunger Conscious

18. Modulators of Wanting Time 9 P.M. Couch TV coffee table sitting end of day dark outside SubconsciousConscious Permission Thoughts Wanting Non Expectancy Counter Dialogue VS. Consequences NegativeE motions Priming Exercise Hunger

19. Non Expectancy Time 9 P.M. Couch TV coffee table sitting end of day dark outside SubconsciousConscious Permission Thoughts Wanting Non Expectancy Counter Dialogue VS. Consequences NegativeE motions Priming Exercise Hunger

20. Permission Thinking Time 9 P.M. Couch TV coffee table sitting end of day dark outside SubconsciousConscious Permission Thoughts Wanting Non Expectancy Counter Dialogue VS. Consequences NegativeE motions Priming Exercise Hunger

21. Counter Dialogue Development Time 9 P.M. Couch TV coffee table sitting end of day dark outside SubconsciousConscious Permission Thoughts Wanting Non Expectancy Counter Dialogue VS. Consequences NegativeE motions Priming Exercise Hunger

22. Case example Patient : Big Dinnerer + Night eating pattern Total 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

23. 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.

24. Overcoming Overeating Thank You! Questions? David Macklin MD CCFP Director, Weight Management Medcan Weight Management