Contingency management adapted for African-American adolescents with obesity enhances youth weight loss with caregiver participation: a multiple baseline pilot study

Study protocol for clinical trial of the FIT Families multicomponent obesity intervention for African American adolescents and their caregivers: Next step from the ORBIT initiative

INTRODUCTION

This study will test the effectiveness of FIT Families (FIT), a multicomponent family-based behavioural intervention, against a credible attention control condition, Home-Based Family Support (HBFS). This protocol paper describes the design of a randomised clinical trial testing the efficacy of the FIT intervention. The protocol will assess the efficacy of FIT to improve health status in African American adolescents with obesity (AAAO) and their primary caregivers on primary (percent body fat) and secondary (physical activity, metabolic control, weight loss) outcomes and its cost-effectiveness.

METHODS

180 youth/caregiver dyads are randomised into FIT or HBFS, stratified by age, gender and baseline per cent overweight. The proposed study follows a two condition (FIT, HBFS) by four assessment time points. Tests will be conducted to identify potential relationship of baseline demographic and clinical variables to our dependent variables and see whether they are balanced between groups. It is hypothesised that youth/caregiver dyads randomised to FIT will show significantly greater reductions in percent body fat over a 12-month follow-up period compared with AAAO receiving HBFS. Preliminary findings are expected by November 2023.

ETHICS

This protocol received IRB approval from the Medical University of South Carolina (Pro00106021; see 'MUSC IRB 106021 Main Approval.doxc' in online supplemental materials).

DISSEMINATION

Dissemination activities will include summary documents designed for distribution to the broader medical community/family audience and submission of manuscripts, based on study results, to relevant peer-reviewed scientific high-impact journals.

TRIAL REGISTRATION NUMBER

NCT04974554.

Role of Dual-Contingency Management in Family-Based Obesity Therapy and the Effects of Weight Loss on Liver Transient Elastography Parameters in Youth: A Pilot Study

The pilot study evaluated contingency management (CM) for family-based obesity therapy (FBT). The secondary outcome assessed the association of the hepatic transient electrography (TE) parameters, including the controlled attenuation parameter (CAP) and liver stiffness (LSM), and changes in liver function blood tests and BMI changes in youth involved in intensive FBT. It included youth-parent dyads from an urban pediatric center randomized to weekly behavioral therapy (BT, n= 4) who received fixed financial compensation for attendance, or BT+CM (n= 5) who received an escalating monetary reward for weight loss. At week 30, all youth and parents had weight-loss trends without significant differences between groups. While the TE measures and blood tests were normal in the youth at baseline and week 30, the CAP changes correlated with BMI changes (R²= 0.86, P< 0.001) and LSM changes with alanine aminotransferase changes (R²= 0.79, P=0.005). In conclusion, BT+CM did not significantly add to the BMI improvement seen with BT alone in youth and their parents. However, in youth with obesity and normal liver blood tests, TE may be useful for monitoring changes in fatty liver disease.

Clinical review: Implementation of trauma informed care to optimally impact the treatment of childhood obesity

Background

Traumatic events that occur in infancy, childhood, and adolescence can be impactful over the course of a lifespan. Adverse childhood experiences (ACEs) are associated with chronic health problems and mental illness, and can negatively impact educational and job opportunities. There is a growing body of evidence about the relationship between ACEs and the risk of childhood obesity. Trauma informed care (TIC) is an approach to patient care both at the clinical and organizational level that is responsive to the impact past trauma can have on an individual.

Methods

This clinical review will focus on the impact of toxic stress from trauma on the child through threats to normal physiology, including the manifestation of obesity through energy regulation pathophysiology, followed by a discussion of TIC principles. Available resources and how trauma informed principles can be used in practice are discussed using case study methodology.

Results

TIC programs recognize the impact of trauma on both patients and clinicians. TIC implementation includes application of TIC four assumptions and six key principles out-lined by Substance Abuse and Mental Health Services Administration's guidance. Clinicians supported by well-designed systems recognize that disclosure is not the goal of TIC; instead, broad trauma inquiry, proceeding to risk and safety assessment if indicated, and connection to interventions is the focus. Best practice communication allows clinicians to access information without retraumatizing the patient with ongoing repetition of their trauma experience.

Conclusion

Combining the pillars of obesity treatment (i.e., nutrition, physical activity, behavior therapy, medical management) with the tenets of TIC (realize, recognize, respond, resist re-traumatization) affords patients holistic, intentional care and family support. The desired outcomes of TIC align with goals of obesity treatment in children, namely improvement of health and quality of life, sense of self (e.g., body image and self-esteem), and prevention of negative health outcomes.

Contingency management for individuals with chronic health conditions: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Contingency management (CM) interventions involve providing reinforcement for engaging in a desired behavior, and have been shown to increase treatment adherence and promote abstinence in the treatment of substance use disorders. This review was conducted to systematically review the literature on the effectiveness of CM when applied to a range of medical conditions outside of substance use disorders.

METHOD

The authors identified a total of 24 randomized studies examining the effects of CM on four outcomes: weight change, physical activity, medication/device adherence, and viral load that were included in the qualitative summary, and 20 studies included in the meta-analysis.

RESULTS

CM was associated with positive outcomes for physical activity and medication/device adherence compared to control conditions. Findings with weight loss and viral load were more mixed, and evidence for publication bias was found for both outcomes. The effects of CM tend to dissipate when the contingency is removed. Heterogeneity was observed across most outcomes.

LIMITATIONS AND CONCLUSIONS

This review provides preliminary support for the use of CM in increasing physical activity and improving adherence to medication for chronic health conditions while reinforcement is ongoing. Future studies should examine potential moderators and identify strategies to maintain these changes over time.

Outcomes From a Sequential Multiple Assignment Randomized Trial of Weight Loss Strategies for African American Adolescents With Obesity

BACKGROUND

Minority adolescents are at highest risk for obesity and extreme obesity; yet, there are few clinical trials targeting African American adolescents with obesity.

PURPOSE

The purpose of the study was to develop an adaptive family-based behavioral obesity treatment for African American adolescents using a sequential multiple assignment randomized trial (SMART) design.

METHODS

Fit Families was a SMART where 181 African American adolescents (67% female) aged 12-17 were first randomized to office-based versus home-based behavioral skills treatment delivered from a Motivational Interviewing foundation. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based behavioral skills treatment or contingency management with voucher-based reinforcement for adolescent weight loss and for caregiver adherence to the program. All interventions were delivered by community health workers. The primary outcome was treatment retention and percent overweight.

RESULTS

All adolescents reduced percent overweight by -3.20%; there were no significant differences in percent overweight based on treatment sequence. Adolescents receiving home-based delivery in Phase 1 and contingency management in Phase 2 completed significantly more sessions than those receiving office-based treatment and continued skills without CM (M = 8.03, SD = 3.24 and M = 6.62, SD = 2.95, respectively). The effect of contingency management was strongest among older and those with lower baseline confidence. Younger adolescents experienced greater weight reductions when receiving continued skills (-4.90% compared with -.02%).

CONCLUSIONS

Behavioral skills training can be successfully delivered to African American adolescents with obesity and their caregivers by community health workers when using a home-based service model with incentives. More potent interventions are needed to increase reductions in percent overweight and may need to be developmentally tailored for younger and older adolescents.

Guidance for reporting intervention development studies in health research (GUIDED): an evidence-based consensus study

OBJECTIVE

To improve the quality and consistency of intervention development reporting in health research.

DESIGN

This was a consensus exercise consisting of two simultaneous and identical three-round e-Delphi studies (one with experts in intervention development and one with wider stakeholders including funders, journal editors and public involvement members), followed by a consensus workshop. Delphi items were systematically derived from two preceding systematic reviews and a qualitative interview study.

PARTICIPANTS

Intervention developers (n=26) and wider stakeholders (n=18) from the UK, North America and Europe participated in separate e-Delphi studies. Intervention developers (n=13) and wider stakeholders (n=13) participated in a 1-day consensus workshop.

RESULTS

e-Delphi participants achieved consensus on 15 reporting items. Following feedback from the consensus meeting, the final inclusion and wording of 14 items with description and explanations for each item were agreed. Items focus on context, purpose, target population, approaches, evidence, theory, guiding principles, stakeholder contribution, changes in content or format during the development process, required changes for subgroups, continuing uncertainties, and open access publication. They form the GUIDED (GUIDance for the rEporting of intervention Development) checklist, which contains a description and explanation of each item, alongside examples of good reporting.

CONCLUSIONS

Consensus-based reporting guidance for intervention development in health research is now available for publishers and researchers to use. GUIDED has the potential to lead to greater transparency, and enhance quality and improve learning about intervention development research and practice.

Changes in delay discounting, substance use, and weight status across adolescence

OBJECTIVE

Higher rates of delay discounting have been consistently linked to maladaptive health behaviors, including substance use and overeating, among adults. Despite adolescence representing a critical period for the escalation of these risky health behaviors, little is known about the developmental course of delay discounting or how this construct relates to important health outcomes in youth. The current study examined change in delay discounting over time using a latent growth curve approach and the relation between growth in this construct and changes in substance use and body-mass index over a 6-year period.

METHOD

Participants included 247 adolescents (44% female) with a mean age of 13 at the initial assessment.

RESULTS

Findings suggest that, on average, rates of delay discounting are stable across adolescence; however, there are significant individual differences around this trajectory. Moreover, youth who demonstrate significant increases in delay discounting over time are also more likely to experience more rapid escalations of both substance use and Body Mass Index across adolescence.

CONCLUSIONS

Results indicate that delay discounting is an important trans-disease process among adolescents. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

African-American Adolescents' Weight Loss Skills Utilization: Effects on Weight Change in a Sequential Multiple Assignment Randomized Trial

OBJECTIVE

Successful weight loss interventions for African-Americans adolescents are lacking. Cognitive-behavioral interventions seek to develop weight loss skills (e.g., counting calories, goal setting, managing one's environment). Little is known about how well adolescents implement such skills in their daily lives. Study aims were to (1) examine weight loss skills utilization at midpoint and end of a 6-month cognitive-behavioral/motivational interviewing weight loss sequential multiple assignment randomized trial (SMART), and (2) determine if greater skill utilization predicted weight loss at treatment end and 3 months post-treatment.

METHOD

One hundred and eighty six African-Americans adolescents with obesity and their caregiver were first randomly assigned to complete 3 months of cognitive-behavioral and motivational interviewing family-based weight loss treatment in their home or in the research office (Phase 1). Nonresponders (i.e., those who lost < 3% of initial weight, n = 161) were rerandomized to 3 months of continued skills training (n = 83) or contingency management (n = 78) for Phase 2; responders were allocated to 3 months of relapse prevention (n = 20). Adolescents' frequency of weight loss skills utilization was assessed via questionnaire at treatment midpoint and end.

RESULTS

Higher treatment attendance was associated with better skill utilization. Higher skill utilization was associated with more weight loss at treatment end, whereas higher baseline confidence was associated with more weight loss at follow-up.

CONCLUSIONS

This study indicates the importance of attending weight loss intervention sessions to develop and strengthen weight loss skills in African-American adolescents with obesity, and strengthening confidence to use such skills for continued weight loss.

Behavioral interventions for obesity in children and adults: Evidence base, novel approaches, and translation into practice

Obesity in adults has nearly doubled in the past 30 years and has risen similarly in children and adolescents. Obesity affects all systems of the body, and the serious health consequences of obesity include an increased risk for cardiovascular disease, such as Type 2 diabetes or high blood pressure, which are occurring at ever younger ages. The present article introduces traditional behavioral weight loss strategies designed to change energy-balance behaviors (i.e., dietary and physical activity behaviors) and the contexts within which these interventions have typically been delivered. The applicability of findings from behavioral economics, cognitive processing, and clinical research that may lead to more potent weight loss and weight loss maintenance interventions are also considered. Given the pervasiveness of obesity, this article concludes with a discussion of efforts toward wider scale dissemination and implementation of behavioral treatments designed to address obesity and to reduce the risk of cardiovascular disease. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Behavioral sensitization of the reinforcing value of food: What food and drugs have in common

Sensitization is a basic property of the nervous system whereby repeated exposure to a stimulus results in an increase in responding to that stimulus. This increase in responding contributes to difficulty with treatment of drug abuse, as stimuli associated with substance use become signals or triggers for drug craving and relapse. Our work over the past decade has applied the theoretical framework of incentive sensitization to overeating. We have shown, in several studies, that lean adults do not commonly demonstrate behavioral sensitization after repeated exposure to snack food, but a subset of obese adults reliably does. This review will discuss this change in behavioral response to repeated consumption of snack food in obese individuals and apply the theoretical framework of incentive sensitization to drugs of abuse to high fat/high sugar snack foods. We will also show data that suggest that behavioral sensitization to repeated administration of snack food is predictive of weight gain, which may enhance its utility as a diagnostic tool for identifying at-risk individuals for obesity. Finally, we will discuss the future directions of this line of research, including studying the phenomenon in children and adolescents and determining if similar principles can be used to increase motivation to eat healthier food. A combination of reductions in unhealthy food intake and increases and healthy food intake is necessary to reduce obesity rates and improve health.

Contingency Management Approaches for Adolescent Substance Use Disorders

Multiple interventions for treating adolescents with substance use disorders have demonstrated efficacy, but a majority of teens do not show an enduring positive response to these treatments. Contingency management (CM)-based strategies provide a promising alternative, and clinical research focused on the development and testing of innovative CM models continues to grow. This article provides an updated review on the progress made in this area. It is important to continue to search for more effective models, focus on post-treatment maintenance (reduce relapse), and strive for high levels of integrity and fidelity during dissemination efforts to optimize outcomes.