Stress, race, and cognitive mediators of SES-related disparities in behavioral obesity treatment outcomes

PROJECT SUMMARY/ABSTRACT
Individuals of lower socioeconomic status (SES) lose only half as much weight in behavioral weight loss
interventions as those of higher SES. This is a clinically meaningful difference in outcomes that has been
consistently documented. The overarching aim of this project is to identify the mechanisms that account for
SES-related disparities in behavioral weight loss outcomes, which would enable the development of more
effective obesity treatment approaches for lower SES populations. One potential mechanism is present bias,
which is a tendency to focus on one’s immediate needs that may result from exposure to harsh and
unpredictable environments. Present bias is a compelling candidate as a mechanism of SES-related disparities
in weight loss outcomes because it is much more pronounced in lower SES populations, and it has been linked
to obesity risk, maladaptive eating behaviors, and poor diet quality. A second set of potential mechanisms
includes adverse daily experiences such as stress, cognitive demands, and exposure to tempting foods. Stress
and cognitive demands are more prevalent or severe in the lives of lower SES populations, and can disrupt the
executive functions that are important for adhering to weight control behaviors during obesity treatment.
This project will allocate equal numbers of subjects of lower and higher SES to a standard-of-care weight loss
intervention. Importantly, the SES groups will be balanced with respect to ethnic/racial minority status. Weight
loss outcomes and adherence to three key weight control behaviors (dietary lapses, dietary self-monitoring,
and physical activity) will be rigorously measured across six months of follow up. Individual differences in
present bias will be thoroughly assessed at baseline. Ecological momentary assessment will be used to
capture exposure to adverse daily experiences, as well as momentary changes in present bias. Aim 1 is to test
whether present bias accounts for SES-related disparities in behavioral weight loss outcomes and adherence
to key weight control behaviors. Aims 2a and 2b will characterize the role of adverse daily experiences in SES-
related disparities in weight loss outcomes and adherence to weight control behaviors, both overall and among
present-biased individuals in particular. Aim 3 is to explore the contribution of race to SES-related disparities in
weight loss outcomes, which has been challenging to elucidate in prior studies due to significant confounding
of race and SES at the societal level. The results of this study could lead to a new understanding of how
socioeconomic disadvantage impacts adherence to behavioral treatment for obesity, and suggest entirely new
treatment approaches focused on mitigating present bias or delivering tailored intervention content during
“moments of risk” for lapses in adherence.

Grant Number: 5R01HL156622-04
NIH Institute/Center: NIH
Principal Investigator: Bradley Appelhans