Adapting Episodic Future Thinking for Behavioral Weight Loss: Comparing Strategies and Characterizing Treatment Response

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Project Summary/Abstract Obesity is one of the most important public health issues today, contributing to many of the leading causes of morbidity and mortality in the United States. Despite strong desires to achieve long-term weight loss goals, individuals with obesity tend to overvalue immediate rewards and discount the future. Episodic Future Thinking (EFT), a cognitive strategy in which individuals envision themselves in the future and simulate potential experiences, has been shown to help shift attention to the future, improve food choices, and reduce intake. Most previous studies have used promotion-focused EFT, in which participants envision themselves experiencing positive future outcomes. However, theories suggest it is possible EFT-based strategies may be alternatively focused on prevention, guiding participants to consider future consequences of unhealthy choices. Our recent pilot (R03 DK106405) randomized controlled trial implemented these approaches in a 3-month Internet-delivered behavioral weight loss program (iBWL). Participants (n=95) were randomized to either: (1) Standard iBWL (no EFT-based strategies), (2) PREVENT (iBWL + EFT-based strategies focused on preventing long-term negative consequences of unhealthy choices), or (3) PROMOTE (iBWL + EFT-based strategies focused on promoting long-term benefits of healthy choices). PREVENT was superior to standard iBWL producing the greatest overall weight loss, which was coupled with reduced food reward drive and increased self-control. This is consistent with our previous work in which use of the PREVENT strategy was associated with reduced craving and increased inhibitory control neural activity. Although PREVENT produced the greatest weight loss, variability suggests individual differences may moderate success in each treatment. For instance, individuals high in promotion-focus were more likely to have greater weight loss in PROMOTE. We now propose a fully powered randomized controlled trial (RCT) to test if either of these novel approaches may provide benefit over standard treatment. Further, the proposed study will seek to identify moderators that predict success, determining for whom each strategy is best. Individuals with overweight/obesity (n=360) will be randomized to 12 months of either (1) Standard iBWL, (2) PREVENT, or (3) PROMOTE. All participants will have an introductory training session, during which PREVENT and PROMOTE groups will receive training in their specific EFT-based strategy. iBWL lessons will then be weekly for 3 months followed by a ‘refresher’ training session for all groups, and monthly iBWL for the remaining 9 months. In PREVENT and PROMOTE iBWL lessons and feedback messages will continuously feature exercises and reminders to utilize the assigned EFT-based strategies. Assessments will be conducted at baseline, during treatment at 3 and 6 months, at the end of treatment (12 months), and 6 months post-treatment (18 months). The primary outcome is weight change. This RCT will provide critical insight into novel treatment strategies for improving weight loss and may lead to future optimization of weight loss via individually tailored treatment.