Refining an algorithm-powered just-in-time adaptive weight control intervention: A randomized controlled trial evaluating model performance and behavioral outcomes.

Suboptimal weight losses are partially attributable to lapses from a prescribed diet. We developed an app (OnTrack) that uses ecological momentary assessment to measure dietary lapses and relevant lapse triggers and provides personalized intervention using machine learning. Initially, tension between user burden and complete data was resolved by presenting a subset of lapse trigger questions per ecological momentary assessment survey. However, this produced substantial missing data, which could reduce algorithm performance. We examined the effect of more questions per ecological momentary assessment survey on algorithm performance, app utilization, and behavioral outcomes. Participants with overweight/obesity (n = 121) used a 10-week mobile weight loss program and were randomized to OnTrack-short (i.e. 8 questions/survey) or OnTrack-long (i.e. 17 questions/survey). Additional questions reduced ecological momentary assessment adherence; however, increased data completeness improved algorithm performance. There were no differences in perceived effectiveness, app utilization, or behavioral outcomes. Minimal differences in utilization and perceived effectiveness likely contributed to similar behavioral outcomes across various conditions.

Application of Machine Learning to Predict Dietary Lapses During Weight Loss.

BACKGROUND: Individuals who adhere to dietary guidelines provided during weight loss interventions tend to be more successful with weight control. Any deviation from dietary guidelines can be referred to as a "lapse." There is a growing body of research showing that lapses are predictable using a variety of physiological, environmental, and psychological indicators. With recent technological advancements, it may be possible to assess these triggers and predict dietary lapses in real time. The current study sought to use machine learning techniques to predict lapses and evaluate the utility of combining both group- and individual-level data to enhance lapse prediction. METHODS: The current study trained and tested a machine learning algorithm capable of predicting dietary lapses from a behavioral weight loss program among adults with overweight/obesity (n = 12). Participants were asked to follow a weight control diet for 6 weeks and complete ecological momentary assessment (EMA; repeated brief surveys delivered via smartphone) regarding dietary lapses and relevant triggers. RESULTS: WEKA decision trees were used to predict lapses with an accuracy of 0.72 for the group of participants. However, generalization of the group algorithm to each individual was poor, and as such, group- and individual-level data were combined to improve prediction. The findings suggest that 4 weeks of individual data collection is recommended to attain optimal model performance. CONCLUSIONS: The predictive algorithm could be utilized to provide in-the-moment interventions to prevent dietary lapses and therefore enhance weight losses. Furthermore, methods in the current study could be translated to other types of health behavior lapses.

Differential Programming Needs of College Students Preferring Web-Based Versus In-Person Physical Activity Programs.

College students report several barriers to exercise, highlighting a need for university-based programs that address these challenges. In contrast to in-person interventions, several web-based programs have been developed to enhance program engagement by increasing ease of access and lowering the necessary level of commitment to participate. Unfortunately, web-based programs continue to struggle with engagement and less-than-ideal outcomes. One explanation for this discrepancy is that different intervention modalities may attract students with distinctive activity patterns, motivators, barriers, and program needs. However, no studies have formally evaluated intervention modality preference (e.g., web-based or in-person) among college students. The current study sought to examine the relationship between intervention modality preference and physical activity programming needs. Undergraduate students (n = 157) enrolled in psychology courses at an urban university were asked to complete an online survey regarding current activity patterns and physical activity program preferences. Participants preferring web-based physical activity programs exercised less (p = .05), were less confident in their abilities to exercise (p = .01), were less likely to endorse the maintenance stage of change (p < .01) and perceived more barriers to exercising (p < .01) than those who preferred in-person programming. Findings suggest that students preferring web-based programming may require programs that enhance self-efficacy by fostering goal-setting and problem-solving skills. A user-centered design approach may enhance the engagement (and therefore effectiveness) of physical activity promotion programs for college students.

Internet-Delivered Acceptance-Based Cognitive-Behavioral Intervention for Social Anxiety Disorder With and Without Therapist Support: A Randomized Trial.

Social anxiety disorder (SAD) is one of the most prevalent psychiatric disorders in the United States. Although evidenced-based behavioral treatments are available, less than 20% of those with SAD receive treatment. Internet-based interventions can address barriers to treatment access, and guided Internet-based treatments have been demonstrated to be effective for SAD. However, the optimal role (if any) of the therapist in such programs remains unclear. We examined the acceptability and efficacy of a novel Internet-based cognitive-behavior therapy for SAD that utilizes traditional behavioral interventions (e.g., exposure) within the context of a model emphasizing mindfulness and psychological acceptance. Forty-two participants were randomized to an eight-module self-help intervention with ( n = 20) or without ( n = 22) adjunctive therapist support; the therapist support was delivered through 10 to 15 min of weekly videoconferencing and daily text messages. Both groups experienced a significant reduction in SAD symptoms and improvements in functioning and quality of life, with no significant differences between groups in both completer-only and intent-to-treat analyses. However, the therapist support group evidenced lower attrition than the minimal support group (20% vs. 50%). Implications for dissemination and future directions are discussed.

Project HELP: a Remotely Delivered Behavioral Intervention for Weight Regain after Bariatric Surgery.

BACKGROUND: Weight regain following bariatric surgery is common and potentially compromises the health benefits initially attained after surgery. Poor compliance to dietary and physical activity prescriptions is believed to be largely responsible for weight regain. Patients may benefit from developing specialized psychological skills necessary to engage in positive health behaviors over the long term. Unfortunately, patients often face challenges to physically returning to the bariatric surgery program for support in developing and maintaining these behaviors. Remotely delivered interventions, in contrast, can be conveniently delivered to the patient and have been found efficacious for a number of health problems, including obesity. To date, they have received little attention with bariatric surgery patients. The study aimed to evaluate a newly developed, remote acceptance-based behavioral intervention for postoperative weight regain. METHODS: Patients at least 1.5 years out from surgery who experienced postoperative weight regain were recruited to receive the 10-week intervention. Participants were assessed at baseline, mid-treatment, post-treatment, and at 3-month follow-up. RESULTS: Support for the intervention's feasibility and acceptability was achieved, with 70 % retention among those who started the program and a high mean rating (4.7 out of 5.0) of program satisfaction among study completers. On average, weight regain was reversed with a mean weight loss of 5.1 ± 5.5 % throughout the intervention. This weight loss was maintained at 3-month follow-up. Significant improvements in eating-related and acceptance-based variables also were observed. CONCLUSIONS: This pilot study provides initial support for the feasibility, acceptability, and preliminary efficacy of a remotely delivered acceptance-based behavioral intervention for postoperative weight regain.

The relationship between dorsolateral prefrontal activation and speech performance-based social anxiety using functional near infrared spectroscopy.

Functional near-infrared (fNIR) spectroscopy is a promising new technology that has demonstrated utility in the study of normal human cognition. We utilized fNIR spectroscopy to examine the effect of social anxiety and performance on hemodynamic activity in the dorsolateral prefrontal cortex (DLPFC). Socially phobic participants and non-clinical participants with varying levels of social anxiety completed a public speaking task in front of a small virtual audience while the DLPFC was being monitored by the fNIR device. The relationship between anxiety and both blood volume (BV) and deoxygenated hemoglobin (Hb) varied significantly as a function of speech performance, such that individuals with low social anxiety who performed well showed an increase in DLPFC activation relative to those who did not perform well. This result suggests that effortful thinking and/or efficient top-down inhibitory control may have been required to complete an impromptu speech task with good performance. In contrast, good performers who were highly socially anxious showed lower DLPFC activation relative to good performers who were low in social anxiety, suggesting autopilot thinking or less-effortful thinking. In poor performers, slight increases in DLPFC activation were observed from low to highly anxious individuals, which may reflect a shift from effortless thinking to heightened self-focused attention. Heightened self-focused attention, poor inhibitory control resulting in excessive fear or anxiety, or low motivation may lower performance. These results suggest that there can be different underlying mechanisms in the brain that affect the level of speech performance in individuals with varying degrees of social anxiety. This study highlights the utility of the fNIR device in the assessment of changes in DLPFC in response to exposure to realistic phobic stimuli, and further supports the potential utility of this technology in the study of the neurophysiology of anxiety disorders.

Can evaluative conditioning decrease soft drink consumption?

The present study examined the effect of a picture-picture evaluative conditioning (EC) procedure on soft drink (soda) outcomes, including negative implicit attitudes, consumption during a taste test, and real-world consumption reported during the week after the intervention. In the EC condition (n = 43), soda images were paired with disgust images and water images were paired with pleasant images, whereas in the control condition (n = 41), the same images were viewed without pairing. The EC condition showed a larger reduction in real-world soda consumption across the week following the intervention. However, individuals in the EC condition did not consume less soda during a taste test immediately following the intervention. EC only significantly increased negative implicit attitudes towards soda among individuals who already had relatively higher baseline negative attitudes. These findings generally favored the potential for EC to impact soda drinking habits, but suggest that a brief EC intervention may not be strong enough to change attitudes towards a well-known brand unless negative attitudes are already present.

A Pilot Study of an Acceptance-Based Behavioral Intervention for Weight Regain After Bariatric Surgery.

BACKGROUND: Tens of thousands of bariatric surgery patients each year experience sub-optimal weight loss, significant regain, or both. Weight regain can contribute to a worsening of weight-related co-morbidities, and for some, leads to secondary surgical procedures. Poor weight outcomes have been associated with decreased compliance to the recommended postoperative diet. Decreased compliance may be partially due to a lack of psychological skills necessary to engage in healthy eating behaviors over the long term, especially as the effects of surgery (on appetite, hunger, and desire for food) decrease. Many behavioral interventions do not sufficiently address these challenges and often have limited effectiveness. The study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness of a novel 10-week acceptance-based behavioral intervention to stop postoperative weight regain. METHODS: A sample of bariatric surgery patients (n = 11) who regained at least 10 % of their maximum lost postoperative weight was recruited. All participants received the intervention, which emphasized psychological skills thought to be integral to successful weight control post-surgery. RESULTS: The intervention was shown to be feasible and acceptable, with 72 % retention and high mean rating (4.25 out of 5.00) of program satisfaction among completers. Weight regain was stopped, and even reversed, with a mean total body weight loss of 3.58 ± 3.02 % throughout the 10-week intervention. There were also significant improvements in eating-related and acceptance-related variables. CONCLUSIONS: These findings provide initial support for the use of a psychological acceptance-based intervention for weight regain in bariatric surgery patients.

The Effects of a Brief Acceptance-Based Behavioral Treatment Versus Traditional Cognitive-Behavioral Treatment for Public Speaking Anxiety: An Exploratory Trial Examining Differential Effects on Performance and Neurophysiology.

Individuals with public speaking anxiety (PSA) experience fear and avoidance that can cause extreme distress, impaired speaking performance, and associated problems in psychosocial functioning. Most extant interventions for PSA emphasize anxiety reduction rather than enhancing behavioral performance. We compared the efficacy of two brief cognitive-behavioral interventions, a traditional cognitive-behavior treatment (tCBT) and an acceptance-based behavior treatment (ABBT), on public speaking performance and anxiety in a clinical sample of persons with PSA. The effects of treatment on prefrontal brain activation were also examined. Participants (n = 21) were randomized to 90 min of an ABBT or a tCBT intervention. Assessments took place at pre- and post-treatment and included self-rated anxiety and observer-rated performance measures, a behavioral assessment, and prefrontal cortical activity measurements using functional near-infrared spectroscopy (fNIRS). Exploratory results indicated that participants in the ABBT condition experienced greater improvements in observer-rated performance relative to those in the tCBT condition, while those in the tCBT condition experienced greater reductions in subjective anxiety levels. Individuals in the ABBT condition also exhibited a trend toward greater treatment-related reductions in blood volume in the left dorsolateral prefrontal cortex relative to those who received tCBT. Overall, these findings preliminarily suggest that acceptance-based treatments may free more cognitive resources in comparison with tCBT, possibly resulting in greater improvements in objectively rated behavioral performances for ABBT interventions.

A Survey of Bariatric Surgery Patients' Interest in Postoperative Interventions.

BACKGROUND: A substantial minority of bariatric surgery patients display clinically significant weight regain and recurrence of obesity-related comorbidities. Although postoperative follow-up and behavioral interventions are associated with better weight loss outcomes, many patients fail to attend or receive these services. More information is needed to better target and increase the probability of sustained treatment in those patients experiencing postoperative weight regain. The purpose of this study was to understand the challenges that patients perceive themselves to be facing and assess their receptivity and preferences for postoperative interventions. METHODS: A survey developed by the authors was sent to patients who received bariatric surgery from a program based in an academic medical center between September 2008 and December 2010 (n = 751). RESULTS: Data from 154 responders indicate that the vast majority of individuals who have undergone bariatric surgery are satisfied with surgery and their weight losses; however, most reported being on a trajectory of weight regain. Patients endorsed concerns about both current eating behavior and, additional, future weight regain. In addition, these patients expressed strong interest in participating in postoperative programs aimed at stopping and reversing regain. CONCLUSIONS: The results provide novel information about bariatric surgery patients' receptivity to and preferences for interventions after bariatric surgery.

An open trial of Acceptance-based Separated Family Treatment (ASFT) for adolescents with anorexia nervosa.

Family based-treatments have the most empirical support in the treatment of adolescent anorexia nervosa; yet, a significant percentage of adolescents and their families do not respond to manualized family based treatment (FBT). The aim of this open trial was to conduct a preliminary evaluation of an innovative family-based approach to the treatment of anorexia: Acceptance-based Separated Family Treatment (ASFT). Treatment was grounded in Acceptance and Commitment Therapy (ACT), delivered in a separated format, and included an ACT-informed skills program. Adolescents (ages 12-18) with anorexia or sub-threshold anorexia and their families received 20 treatment sessions over 24 weeks. Outcome indices included eating disorder symptomatology reported by the parent and adolescent, percentage of expected body weight achieved, and changes in psychological acceptance/avoidance. Half of the adolescents (48.0%) met criteria for full remission at the end of treatment, 29.8% met criteria for partial remission, and 21.3% did not improve. Overall, adolescents had a significant reduction in eating disorder symptoms and reached expected body weight. Treatment resulted in changes in psychological acceptance in the expected direction for both parents and adolescents. This open trial provides preliminary evidence for the feasibility, acceptability, and efficacy of ASFT for adolescents with anorexia. Directions for future research are discussed.

Acceptance-based treatment and quality of life among patients with an eating disorder.

This study assessed the relationship between acceptance-based constructs and quality of life (QOL) among patients with an eating disorder, as well as whether an acceptance-based treatment group could improve QOL. Patients (n = 105) at a residential treatment center received treatment as usual (TAU) or TAU plus twice-weekly acceptance and commitment therapy groups (TAU+ACT), and completed assessments at admission and discharge. Higher scores on several acceptance-related constructs at admission were associated with better psychological QOL, and pre- to post-treatment improvements in the ability to defuse from distressing internal experiences were associated with improved QOL. However, no differences in pre- to post-treatment changes in QOL were observed between treatment conditions. These results suggest that while some acceptance-related variables (e.g. defusion, impulse control, access to emotion regulation skills) may contribute to QOL, ACT does not appear to incrementally improve these variables or QOL beyond standard treatment programs. Additional research is needed to evaluate whether ACT may confer greater benefit for improving QOL in an outpatient setting where patients have more opportunity to utilize ACT skills, or when a stronger dose of treatment is administered.

An open trial of videoconference-mediated exposure and ritual prevention for obsessive-compulsive disorder.

The gold-standard treatment for OCD is exposure and ritual prevention (ERP), yet despite its well-established efficacy, only a small percentage of OCD patients have access to this treatment. Remote treatments (e.g., videoconferencing) are becoming increasingly popular avenues for treatment delivery and show promise in increasing patient access to evidence-based mental health care. The current pilot study utilized an open trial to examine the feasibility and preliminary efficacy of videoconference-mediated, twice weekly, ERP for adults (n=15) with OCD. Results revealed that ERP was associated with significant improvements in OCD symptoms and large within-group effect sizes. Among the 10 individuals who completed a 3-month follow-up assessment, 30% of participants no longer met DSM-IV-TR criteria for OCD and 80% of participants were rated as very much or much improved on the CGI. This study adds to the growing body of literature suggesting that videoconference-based interventions are viable alternatives to face-to-face treatment.

The discrepancy between implicit and explicit attitudes in predicting disinhibited eating.

Disinhibited eating (i.e., the tendency to overeat, despite intentions not to do so, in the presence of palatable foods or other cues such as emotional stress) is strongly linked with obesity and appears to be associated with both implicit (automatic) and explicit (deliberative) food attitudes. Prior research suggests that a large discrepancy between implicit and explicit food attitudes may contribute to greater levels of disinhibited eating; however this theory has not been directly tested. The current study examined whether the discrepancy between implicit and explicit attitudes towards chocolate could predict both lab-based and self-reported disinhibited eating of chocolate. Results revealed that, whereas neither implicit nor explicit attitudes alone predicted disinhibited eating, absolute attitude discrepancy positively predicted chocolate consumption. Impulsivity moderated this effect, such that discrepancy was less predictive of disinhibited eating for those who exhibited lower levels of impulsivity. The results align with the meta-cognitive model to indicate that attitude discrepancy may be involved in overeating.

mHealth: a mechanism to deliver more accessible, more effective mental health care.

UNLABELLED: The increased popularity and functionality of mobile devices has a number of implications for the delivery of mental health services. Effective use of mobile applications has the potential to (a) increase access to evidence-based care; (b) better inform consumers of care and more actively engage them in treatment; (c) increase the use of evidence-based practices; and (d) enhance care after formal treatment has concluded. The current paper presents an overview of the many potential uses of mobile applications as a means to facilitate ongoing care at various stages of treatment. Examples of current mobile applications in behavioural treatment and research are described, and the implications of such uses are discussed. Finally, we provide recommendations for methods to include mobile applications into current treatment and outline future directions for evaluation. KEY PRACTITIONER MESSAGE: Mobile devices are becoming increasingly common among the adult population and have tremendous potential to advance clinical care. Mobile applications have the potential to enhance clinical care at stages of treatment-from engaging patients in clinical care to facilitating adherence to practices and in maintaining treatment gains. Research is needed to validate the efficacy and effectiveness of mobile applications in clinical practice. Research on such devices must incorporate assessments of usability and adherence in addition to their incremental benefit to treatment.

The importance of theory in cognitive behavior therapy: a perspective of contextual behavioral science.

For the past 30 years, generations of scholars of cognitive behavior therapy (CBT) have expressed concern that clinical practice has abandoned the close links with theory that characterized the earliest days of the field. There is also a widespread assumption that a greater working knowledge of theory will lead to better clinical outcomes, although there is currently very little hard evidence to support this claim. We suggest that the rise of so-called "third generation" models of CBT over the past decade, along with the dissemination of statistical innovations among psychotherapy researchers, have given new life to this old issue. We argue that theory likely does matter to clinical outcomes, and we outline the future research that would be needed to address this conjecture.

Acceptance based behavior therapy for social anxiety disorder through videoconferencing.

Most individuals with social anxiety disorder (SAD) do not receive any type of treatment. Reasons include logistical barriers (e.g., geographic location, travel time), fear of stigmatization, and fear of the social interactions associated with seeking treatment. Videoconferencing technology holds great promise in the widespread delivery of evidence-based treatments to those who would otherwise not receive treatment. This pilot study assessed the feasibility, acceptability, and initial efficacy of an acceptance-based behavioral intervention using Skype videoconferencing to treat adults with generalized SAD. Twenty-four participants received 12 sessions of weekly therapy and were assessed at pre-treatment, mid-treatment, post-treatment, and 3-month follow-up. Participants and therapists rated the intervention as acceptable and feasible. Analyses revealed significant pre-treatment to follow-up improvements in social anxiety, depression, disability, quality of life, and experiential avoidance, with effect sizes comparable to or larger than previously published results of studies delivering in-person CBT for SAD. Implications and future directions are discussed.

Caution: the differences between CT and ACT may be larger (and smaller) than they appear.

Hofmann, Asmundson, & Beck (2013--this issue) offer an overview of cognitive-behavior therapy (CBT) as well as its similarities and differences from so-called "third-generation" behavior therapies, particularly Acceptance and Commitment Therapy (ACT). In this commentary we suggest that CBT is most accurately viewed as a broad family of distinct psychotherapy models that includes the traditional Beckian approach of cognitive therapy as well as newer acceptance-based approaches such as ACT. We argue that Hofmann, Asmundson, & Beck's discussion of the differences in CT and ACT's view of the causal role of cognition lacks clarity. For instance, the behavior analytic framework of ACT does not categorically deny any causal role of cognitions in behavioral and emotional responses. Similarly, we disagree with the authors' contention that CT utilizes primarily antecedent-focused and ACT employs response-focused emotion regulation strategies. In addition, we take the view that the empirical evidence for CT, although very impressive, does not reduce the impetus to innovate. We object to some of Hofmann, Asmundson, & Beck's interpretation of component and mediational analyses and argue that the field does, in fact, need to question CT's postulated mechanism of action (i.e., cognitive change), both on theoretical and pragmatic grounds. At the same time, although preliminary research on ACT is promising, we suggest that its proponents need to be appropriately humble in their claims. In particular, like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects. We conclude that the fundamental differences between CT and ACT are philosophical and theoretical rather than technological.