Problematic Decision-Making and Adolescent Weight Loss
Problematic Decision-Making and Adolescent Weight Loss
This study evaluates the associations between baseline decision-making processes, engagement
 in problematic dietary practices, and post-intervention weight loss outcomes among
 adolescents. Results from the study will provide specific direction for what components
 should comprise future decision-making interventions for adolescents with overweight/obesity.
Adolescent overweight and obesity (AOB; i.e., a body mass index (BMI) greater than 85th
 percentile for age, height, and gender) affects 34.5% of adolescents. Over 80% of obese
 adolescents will become obese adults and experience increased risk of cardiovascular disease,
 type 2 diabetes, gallbladder disease, and some forms of cancer. Because of contraindications
 and hesitations to pursue psychopharmacology or bariatric surgery, behavioral interventions
 are the first-line treatment for AOB. Unfortunately, adolescent outcomes from pediatric
 behavioral obesity treatments are poor. In fact, the modal weight loss in behavioral
 interventions is less than a single BMI point, and many participants lose no weight at all.
 Outcomes in adolescents are worse than those found in younger children and adults. Notably,
 the vast majority of existing interventions tested in adolescents are designed for younger
 children, which may preclude an adolescent's success in these interventions. Successful
 behavioral AOB interventions may require augmentations that address developmental concerns
 unique to adolescence. For example, research has shown that, in contrast to younger children,
 many adolescents are making their own food decisions and are thus more likely to engage in
 problematic eating behaviors during treatment. As a necessary step towards developing
 specialized interventions for AOB, it is critical to understand the underlying mechanisms of
 continued engagement in problematic eating behaviors during AOB interventions.

 Three types of problematic eating behaviors are strongly linked (cross-sectionally and
 longitudinally) with AOB. First, reward-driven overeating (i.e., frequently eating
 energy-dense foods) results in excess calorie intake, which, in turn, produces adiposity
 during childhood and adolescence. Second, loss-of-control eating (LOC; the experience of not
 being able to stop eating once started) is an exceptionally strong predictor of excess weight
 gain, i.e., an additional 2.4kg per year compared to peers without LOC. Third, rigid dietary
 restriction involves skipping meals and cutting out food groups for the purposes of weight
 regulation, but instead results in intense feelings of deprivation. As a result, rigid
 dietary restriction has the paradoxical effect of calorie overconsumption, excess weight
 gain, and poor outcomes from pediatric obesity treatment. Taken together, findings indicate
 that elucidating the drivers of these three problematic eating behaviors is critical to
 improving AOB treatment outcomes.

 An aberrant decision-making framework represents an attractive paradigm for understanding the
 above-described problematic eating behaviors, especially given that they all run counter to
 adolescents' intentions and well-being. There are several aberrant decision-making processes
 endemic to the adolescent developmental period. Three of these processes in particular appear
 to be directly linked to the three problematic eating behaviors described above. To the
 extent that aberrant decision-making produces problematic eating behavior, aberrant
 decision-making can also be hypothesized to predict poor weight loss outcomes. Below, three
 aberrant decision-making processes and their links to problematic eating behavior are
 described.

 Increased delay discounting. Delay discounting refers to the tendency to discount greater,
 later rewards in favor of smaller, sooner rewards. A combination of greater sensitivity to
 reward and slow development of self-regulatory neural processes contributes to especially
 high discounting rates in some adolescents. Relatively higher discounting rates may produce
 reward-driven eating, i.e., frequent consumption of energy-dense foods (e.g., high-fat, high
 sugar foods), while discounting the future reward (e.g., weight loss) that would be derived
 from forgoing immediate gratification. Indeed, a recent meta-analysis concluded that higher
 discounting rates were strongly cross-sectionally linked with AOB. Although behavioral weight
 loss programs discourage consumption of energy-dense foods, psychological strategies for how
 to prioritize long-term over short-term rewards are not provided. Thus, delay discounting
 likely contributes to continued reward-driven eating during treatment. However, no studies
 have tested whether delay discounting predicts reward-driven overeating (and its effect on
 weight) during AOB treatment.

 Affect-driven impulsivity. Affect-driven impulsivity refers to a tendency to choose
 maladaptive behaviors geared towards the immediate cessation of a negative affective state,
 despite negative consequences. Affect-driven impulsivity likely drives continued LOC eating
 during treatment, precluding successful weight loss. Affect-driven impulsivity is a
 cross-sectional predictor of AOB, but it may be a particularly strong driver of LOC eating
 because compulsive eating serves the function of reducing distress. Although no studies have
 compared adolescents with and without LOC on affect-driven impulsivity, adolescents with LOC
 eating demonstrate overall higher levels of emotional reactivity and emotional eating. LOC
 eating resulting from affect-driven impulsivity may continue to occur during treatment
 because little treatment content focuses on skills for tolerating negative affect. Dr.
 Manasse's work demonstrates that increased affect-driven impulsivity predicts poor outcomes
 from adult binge eating treatment. However, no studies have examined whether affect-driven
 impulsivity predicts (1) engagement in LOC during treatment or (2) poor AOB treatment
 outcomes.

 Perseverative decision-making. Perseverative decision-making is characterized by weakened
 ability to stop engagement in habitual behaviors despite changing contingencies. Highly
 perseverative decision-making may contribute to repeated engagement in rigid dietary
 restriction (i.e., setting rigid calorie goals, cutting out specific foods) that increase
 deprivation. This deprivation, in turn, leads to episodes of overeating that preclude
 successful caloric restriction. Those who show highly perseverative decision-making continue
 engaging in this rigid dietary restriction behavior despite the fact that it ultimately
 delivers the opposite of its intended effect. Indeed, perseverative decision-making and rigid
 dieting are associated with the presence of LOC eating, and perseveration is
 cross-sectionally associated with obesity in adolescence. Despite the established links
 between perseverative decision-making with unhealthy dieting and excess weight, no studies
 have examined whether perseverative decision-making underlies continued engagement in
 problematic dietary restriction during treatment and predicts poor outcomes.

 To inform the development of tailored intervention approaches, the current study, funded by
 the National Institutes of Health, aims to elucidate the specific aberrant decision-making
 processes associated with three problematic eating behaviors and weight loss outcomes.
 Results from the study will provide specific direction for what components (e.g., strategies
 for tolerating emotional distress or promoting flexible thinking) should comprise a future
 decision-making intervention for AOB and for whom (e.g., those with LOC, those who engage in
 problematic restriction) certain components would be most relevant. Given that LOC eating is
 a robust predictor of excess weight gain but only 20-30% of those with AOB endorse LOC
 eating, the study team will oversample individuals with clinically significant LOC, i.e., the
 study will recruit a total of 80 adolescents (ages 14-18) with overweight/obesity, half of
 whom (n=40) endorse clinically significant (i.e., at least once weekly) LOC eating and the
 other half of whom (n=40) endorse subclinical LOC or no LOC. All participants will receive a
 16-week group-based, remotely delivered behavioral weight loss intervention and complete a
 6-month follow-up. Decision-making measures will be administered at baseline. Problematic
 eating behaviors and weight will be assessed at all time points.
Inclusion Criteria:

 1. Are between 14 and 18 years of age

 2. Have a BMI between the 85th and 99th percentiles for sex and age as determined by the
 CDC growth charts

 3. Are currently living at home with a parent or guardian

 4. Have at least one parent or guardian who is willing to participate in the study

 5. Are willing to complete baseline assessment tasks

 6. Have a smartphone, are willing to download an app to track food intake and complete
 surveys on the phone for two seven-day periods throughout the course of the study, and
 are willing to wear a fitness tracker during these same two week-long periods

 7. Are located in the US and wiling/able to participate in remote intervention and
 assessments

 Exclusion Criteria:

 1. Acute suicide risk

 2. Inability to engage in physical activity (defined as walking two city blocks without
 stopping)

 3. Have diabetes or a history of bariatric surgery

 4. Current medical or psychiatric condition that may pose a risk to the participant
 during intervention, cause a change in weight, or limit ability to comply with the
 program (i.e., bulimia nervosa, substance abuse disorder, psychosis, bipolar I
 disorder, and/or any condition prohibiting physical activity)

 5. Are pregnant or planning to become pregnant in the next 2 years

 6. Recently began or changed the dose of a medication that can cause significant change
 in weight

 7. Have experienced weight loss ≥ 5% in the previous 6 months

 8. Are planning to begin in the next 16 months, or are currently participating in,
 another weight loss treatment or psychotherapy for binge eating and/or weight loss

 9. Are engaging in compensatory vomiting, other severe compensatory behaviors, or more
 than 12 of any compensatory behaviors in the previous 3 months

 10. Are currently taking medication (e.g., Contrave, Alli, etc.) which is specifically
 intended for weight loss