The leading causes of morbidity and mortality in the U.S. include chronic disease such as the following:
As researchers, we know that in order to prevent and manage chronic diseases, we must also understand and address contextual elements such as health care access and affordability, neighborhood environment and exposure to stressors and discrimination, all of which influence behavioral risk factors associated with chronic diseases, including:
- Poor diet quality
- Physical inactivity
- Tobacco use
- Alcohol use
Thus, we approach our work to combat chronic disease through the lens of these social determinants of health, conducting research to improve risk factors across individual, family, community, health care and population levels. Our efforts also aim to improve treatment adherence and patient-provider communication, reduce disease symptoms and enhance quality of life.
Research within this realm is multidisciplinary in nature, and we are proud to collaborate with key stakeholders outside our department. Our research methods range from efficacy trials to dissemination and implementation efforts.
Co-Investigator: Jessica LaRose, Ph.D.
Funding Source: National Institutes of Health, National Institute of Child Health and Human Development
Project Summary: There is an urgent need for innovative approaches to adolescent obesity treatment, particularly among African Americans (AA), a population at increased risk of obesity and its associated morbidity and mortality. There is a particular dearth of research on the long-term efficacy of adolescent obesity treatments. Further, research and clinical practice guidelines consistently recommend that parents should be included in their adolescents' obesity treatment, yet the most effective strategy to engage parents in adolescent obesity treatment remains unclear.
Towards that end, this investigation (informed by R21HD084930) will conduct a fully powered, randomized controlled trial to examine the efficacy of two distinct approaches to involving parents in their adolescents' obesity treatment. Participants will be 210 12-16-year-old adolescents (BMI>85th percentile) and parents (BMI>25 kg/m2) with overweight or obesity. Families will be randomized to one of two 4-month treatments: 1) TEENS+Parents as Coaches (PAC), engaging parents as helpers in their child's weight management via parent skills training, or 2) TEENS+Parent Weight Loss (PWL), engaging parents in their own behavioral weight management.
All adolescents will participate in the TEENS+ protocol, which includes nutrition education with dietary goals, supervised physical activity, and behavioral support, and integrates motivational interviewing to enhance treatment engagement. Assessments of anthropometrics, dietary intake, physical activity, parenting and home environment variables will be completed at 0, 2, 4, 8, and 12 months with the primary endpoint at 12m follow-up. Results of this investigation have the potential to significantly advance science in this area and ultimately inform clinical practice guidelines related to the role of parents in adolescent obesity treatment.
Co-Investigator: Jessica LaRose, Ph.D.
Funding Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases
Project Summary: Obesity is a public health crisis among adults from economically disadvantaged backgrounds, with more 85% experiencing overweight or obesity and associated health ailments. To date, lifestyle interventions targeting this high-risk group have produced modest weight losses. Thus, effective interventions for this vulnerable population are urgently needed.
New evidence from behavioral economics suggests that targeting lack of reinforcement and bias for the present may improve treatment outcomes in adults from disadvantaged backgrounds. Specifically, impoverished environments have been shown to have few sources of healthy reinforcement, which makes responding to basic sources of reinforcement (e.g., palatable food) more resistant to change. Moreover, all humans have been shown to have bias for the present, or a preference for immediate rewards (palatable food) over future rewards (improved health), and studies suggest that individuals from disadvantaged backgrounds have even greater bias for the present (perhaps due to life demands, stress, and cognitive load). Addressing these two processes (lack of reinforcement and bias for the present) in obesity treatment may uniquely meet the needs of this high-risk, underserved population and result in weight loss success.
The proposed study will test the efficacy of a mHealth behavioral economics weight loss intervention that addresses lack of reinforcement and bias for the present. Lack of reinforcement will be addressed with small monetary reinforcers delivered at the beginning of treatment. Reinforcers will taper during the initial treatment period and eventually end. As reinforcers taper, participants will be trained in episodic future thinking (EFT), which has been shown to reduce bias for the present and may improve longer-term weight loss outcomes. This two-pronged, phased approach that first addresses lack of reinforcement and then bias for the present is essential. Providing reinforcement immediately at treatment start is necessary to engage participants straightaway. Then, as participants are developing success experiences with weight loss, which naturally provides its own reinforcement (improved mood, health, appearance), reinforcers will taper. During this time, EFT training will begin.
This novel behavioral economics mHealth intervention will be compared to a mHealth only intervention. The two interventions will be delivered primarily via a mobile platform, include treatment material tailored to this population, and be matched for contact. Thus, the only way the two interventions will differ is in the inclusion of behavioral economics strategies in BE mHealth. Our primary hypothesis is that the behavioral economics intervention will yield significantly better weight losses at month 12 (treatment end). Mediators (food reinforcement, bias for the present), moderators (stress, resilience, obesogenic environment), and cost-effectiveness will also be explored. If effective, this mHealth behavioral economics intervention would be a new and transformative intervention approach that significantly improves obesity treatment outcomes in a high-risk, underserved population.
Principal Investigator: Jessica LaRose, PhD
Funding Source: VCU School of Medicine VETAR Award
Project Summary: Emerging adulthood (18-25 years) is a distinct period in the life course marked by transition, instability, self- focus, and identity exploration. These years also represent a critical time for the development of obesogenic behaviors, and extant data place the prevalence of overweight/obesity at more than 40% in this population. Given the unique features of emerging adulthood (e.g., transition, instability), it has been difficult to recruit, engage, and retain this population in behavioral weight loss (BWL) trials. Recent efforts to adapt BWL programs for emerging adults have demonstrated improvements in outcomes compared to those seen in standard adult BWL programs, yet modest overall weight losses and tremendous variability in treatment response persist as key challenges. Mounting evidence, including our own preliminary data, highlights several risk factors that are particularly salient in emerging adulthood and predict suboptimal weight loss outcomes in this population— insufficient sleep, exposure to life events, and psychological distress. Of note, each of these risk factors are also associated with physiological states that could predispose emerging adults to poorer treatment response, but this has not been examined in previous research. Further, little is known about how these behavioral and psychological risk factors unfold in real time over the course of emerging adults’ participation in a BWL intervention, which prevents the development of well designed, mechanistic interventions to address these risk factors. Moreover, the frontal lobe is still developing during these years—as such, it is plausible that executive functions could moderate the effects of these risk factors on weight loss outcomes. Thus, the overarching goal of the proposed study is to examine how each of these behavioral and psychological risk factors contribute to variability in weight trajectories and to explore demographic, cognitive and physiological moderators of these associations. We will enroll 45 18-25 year-olds (BMI 25-45 kg/m2, >40% racial / ethnic minority) in a 4-month technology-driven BWL program. At 0 and 4 months, we will assess physical measures in lab (weight, waist, BP, hs-CRP, HOMA-IR), sleep via actigraphy, and life events, perceived stress and depressive symptoms via validated self-report tools; executive functions will be assessed at baseline only via validated lab-based tasks and self-report tools. We will give participants wireless scales and a self-monitoring app to allow for continuous monitoring of self-regulation behaviors. To ensure an ecologically valid assessment of risk factors, we will employ an ecological momentary assessment (EMA) protocol 4 times during the intervention (week 2, 4, 7, 13), coupled with a wearable device for monitoring of sleep and activity. Taken together, these data will provide critical insight as to how sleep (duration, timing), life events (major events, daily hassles) and psychological distress (depressive symptoms, perceived stress) operate in daily life and allow us to examine pathways by which these risk factors could influence weight loss, as well as potential moderators of these associations. It is expected that baseline risk factors will predict poorer overall weight change, with these associations being partially mediated by self-regulation behaviors. Similarly, it is predicted that during EMA weeks, greater daily exposure to risk factors will predict worse weekly weight change, and that this will be partially mediated by self-regulation behaviors. Further, we expect executive function abilities to moderate the effects of risk factors on both weekly and 4-month weight change. We will also explore the extent to which treatment response is moderated by physiological markers associated with these disruptors, and the potential cumulative effects of physiological, behavioral and psychological variables on weight loss treatment response. Findings will provide rich data to inform the development of phenotypes which can assist in future treatment matching efforts, as well as the development of novel intervention approaches for this vulnerable population.
Funding Source: National Institutes of Health / NIDDK Grant No. R01DK132373
Project Summary: African American adults and adults from economically disadvantaged environments are at disproportionate risk for obesity yet are markedly underrepresented in traditional weight management trials and experience lower weight losses relative to their white and socioeconomically advantaged counterparts. Developing sustainable, community-based behavioral interventions to address the national obesity crisis is critical in order to mitigate the alarmingly poor health outcomes faced by underserved populations. Indeed, initiation and maintenance of healthy lifestyle behaviors presents unique challenges in underserved, economically disadvantaged communities, but traditional behavioral weight management delivery models largely disregard the social and cultural assets which exist within these community settings. Moreover, previously tested community-based interventions have not fully harnessed the potential of community members as agents of change within their social networks. Thus, the overall objective of this proposal is to test the feasibility, acceptability and preliminary effectiveness of a grassroots intervention delivery model which includes training community members to recruit and retain members of their social network and to deliver an evidence-based lifestyle intervention to reduce adiposity and improve cardiometabolic risk. The specific aims are: 1) to test the feasibility and acceptability of using house chats (home-based, peer-led focused discussions) as a model for intervention implementation in a real-world, community-based setting; and 2) to assess the preliminary effectiveness of the house chat intervention model for promoting change in behavioral (physical activity, diet) and physical (adiposity, fasting glucose, blood pressure) markers of cardiometabolic risk at post-treatment (12 weeks) and follow up (24 weeks); and 3) to systematically evaluate—using a mixed methods approach—the facilitators and barriers to sustainability of this model. The proposed pilot trial will utilize a group randomized controlled design wherein participants are assigned by ward to either intervention or delayed intervention control. A total of 10 house chat leaders (HCL) will be recruited and trained (5 HCL in each condition). HCL will recruit members of their social network (N=80, 18- 70 years of age) to participate in an 12-week lifestyle intervention delivered via weekly group meetings in the house chat leaders’ homes. In-person assessment visits will be conducted by masked research staff at 0, 12 weeks (post-treatment) and 24 weeks (follow-up). Satisfaction will be assessed in-person at 12 weeks (post- treatment) only via surveys and an exit interview. Facilitators and barriers to sustainability will be assessed via a mix of in-depth interviews (with house chat leaders), focus groups (with participants) and surveys (with both) at 24 weeks. The proposed intervention delivery model, which draws on community assets and builds capacity, could offer a viable approach to improve health outcomes for an underserved population. This pilot trial will provide the first evidence of feasibility and preliminary effectiveness, which will make a meaningful contribution to the field and inform a larger trial.
Co-Investigator: Jessica LaRose, PhD
Funding Source: National Institutes of Health / NICHD
Project Summary: The goal of this project is to examine the familial reach of adolescent obesity treatment to understand how family-level factors impact adolescent weight outcomes. Findings will inform subsequent family-based adolescent obesity interventions that target identified family-level factors directly and improve clinical guidelines regarding family-based treatment of adolescent obesity.