Lauren B. Shomaker, Ph.D. - US grants

[unreadable] DESCRIPTION (provided by applicant): Body dissatisfaction is a robust predictor of eating pathology and depression, two of the most common psychiatric problems faced by females in emerging adulthood. A significant number of emerging adults experience body dissatisfaction, yet little research has systematically investigated psychosocial influences on body dissatisfaction during the transition from late adolescence to emerging adulthood. In addition, very few studies have assessed males' body dissatisfaction or symptoms of pathological muscle-building. This study examines the theoretical model that parent, friend, and romantic partner pressure to be thin or muscular affect late adolescent body dissatisfaction, which in turn leads to symptoms of depression, disordered eating, and muscle-building pathology in emerging adulthood. This model will be explored in a community sample of 200 17-year-olds (50% male) and their mothers, close friends, and romantic partners. Multiple reporters will be used to assess body dissatisfaction and pressure to be thin and muscular. Measures also will assess internalization of cultural ideals of attractiveness, symptoms of depression, disordered eating, and pathological muscle-building. SEM will be used to test a theoretical model of pressure to be thin/muscular, body dissatisfaction, and psychopathology. Internalization of cultural ideals will be tested as a mediator of pressure and body dissatisfaction. LGCM will examine which relationships are most predictive of levels and changes in body dissatisfaction over time. The results will enhance our understanding of psychosocial risk and protective factors for body dissatisfaction in emerging adulthood and will help to foster improvements in clinical preventions and interventions for emerging adults at risk for depression, eating, and/or muscle-building pathology. [unreadable] [unreadable]

[unreadable] DESCRIPTION (provided by applicant): Receipt of this postdoctoral fellowship award would facilitate the applicant's long-term objective to become a productive, independent investigator in the area of adolescent health and development. Lauren Shomaker, PhD has particular interests in social competence and understanding development of disordered eating and co-morbid socio-emotional and behavioral problems. The proposed training plan will enable her to obtain further expertise in pediatric disordered eating and its overlap with obesity, and acquire advanced skills in the methodologies used to study these problems. These goals will be accomplished in the rich training environments of USUHS and NIH, and through research mentorship with two co-sponsors with expertise in the fields of disturbed eating and pediatric obesity (Marian Tanofsky-Kraff, PhD, Jack A . Yanovski, MD, PhD). Dr. Shomaker has put together a strong team of consultants with expertise in diversity in obesity treatment (Nazrat Mirza, MD, ScD), eating in the absence of hunger ( Myles Faith, PhD), eating disorders (J. Kevin Thompson, PhD), and nutrition (Nancy Sebring, MEd, RD). Pediatric overweight has gained increasing recognition as a major public health concern with striking personal, societal, and healthcare costs. Overweight youth are at increased risk for immediate and future physical health problems (e.g., [unreadable] diabetes) and socio-emotional difficulties (e.g., depression). Identification of eating behaviors such as eating in the absence of hunger and disordered eating associated with risk for obesity onset is critical for designing effective interventions. In the proposed project, Dr. Shomaker employs a laboratory design to examine whether eating in the absence of hunger is associated with weight status in adolescence. Participants will be 120 adolescents from a racially and ethnically diverse community sample. Adolescents' caloric intake will be observed during two successive test meals. Adolescents first will eat until they are full and are then presented with access to a different array of highly palatable snack foods. The primary hypothesis is that overweight adolescents will eat more during the second meal (eating in the absence of hunger) than their non-overweight counterparts. The study also aims to examine links between eating in the absence of hunger and disordered eating as assessed by interview and questionnaires. PUBLIC HEALTH RELEVANCE: Additionally, using SEM, a provisional theoretical model of proposed relations among interpersonal interactions, body image, negative affect, depressive symptoms, disordered eating, eating in the absence of hunger, and adolescent overweight will be examined. Such an investigation is a crucial step in facilitating the formation of accurate, integrated models of the temporal sequence of eating behaviors that lead to future obesity and disordered eating. [unreadable] [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Type 2 diabetes (T2D) is a chronic disease accompanied by heightened risk for severe health complications such as cardiovascular and peripheral vascular disease, stroke, blindness, and renal failure. The alarming rise in the manifestation of T2D among adolescents and young adults poses an enormous public health burden. Insulin resistance (IR) is a major physiological precursor to T2D. Thus, prevention efforts targeting modifiable risk factors for IR have the potential to diminish the risk of developing T2D significantly. Depressive symptoms often first appear during adolescence, are associated with IR in adolescents and adults, predict adult-onset T2D, and contribute to increased risk for T2D mortality and morbidity, beyond the interrelationship of depression with obesity. The mechanisms underlying the link between depressive symptoms and IR are unclear. Depressive symptoms theoretically induce IR by promoting stress-induced behaviors (altered eating, lowered fitness) and up regulating physiological stress mechanisms (cortisol, neuropeptide Y). Psychotherapy for depression improves IR in adults, but it is uncertain whether ameliorating depressive symptoms prevent progression of IR in adolescents at risk for T2D. The aims of this proposal are: 1) to assess the effects of a 6-wk cognitive-behavioral (CB) depression prevention group vs. a 6-wk standard-of-care health education (HE) group on reducing depressive symptoms and improving IR in adolescent girls at risk for T2D;2) to assess the stress-related behavioral and physiological factors that mediate the relationship underlying decreases in depressive symptoms and improvements in IR;and 3) to pilot delivery of a mindfulness-based stress reduction (MBSR) group to adolescents girls at risk for T2D. The PI, Dr. Lauren Shomaker, is a child clinical psychologist whose background in adolescent development/psychopathology, eating behavior, and pediatric obesity/obesity related health co-morbidities is uniquely suited to advance the aims in this proposal. During the K99 phase, Dr. Shomaker will obtain training to enhance her expertise in: 1) conduct of randomized controlled trials (RCTs) in adolescents, ii) measurement of IR, and iii) assessment of cardiovascular fitness. Dr. Shomaker has assembled a strong mentoring and consultant team with expertise in RCTs for pediatric obesity and IR (Co- Mentors: Marian Tanofsy-Kraff, PhD, Jack Yanovski, MD, PhD), CB depression interventions (Eric Stice, PhD, Marjan Holloway, PhD), cardiovascular fitness (Kong Chen, PhD), stress physiology (Zofia Zukowska, MD, PhD), advanced statistical analysis (Cara Olsen, PhD), and MBSR (Kirk Brown, PhD). The proposed K99/R00 application is the ideal vehicle to promote Dr. Shomaker's ultimate goal of transitioning to an independent career focused upon the interconnections between adolescent psychosocial development and physical health, and the putative mechanisms underlying the links between psychosocial factors and physical well-being. PUBLIC HEALTH RELEVANCE: Type 2 diabetes (T2D) is one of our nation's most common chronic diseases. It affects >7.8% of the U.S., and the societal cost is >$90 billion/yr. In the past, T2D was considered a disease limited to older adults. Yet, there has been an alarming rise in its manifestation among adolescents and young adults. Early onset T2D has been associated with greater risk of end-stage renal disease and death and a shorter life expectancy of 15-27 yrs. Insulin resistance (IR) is a major physiological precursor to T2D. The normative rise in IR that characterizes puberty may render adolescence a sensitive period, triggering the progression of worsening IR among adolescents at risk for T2D. Adolescence also marks a peak period for the onset of elevated depressive symptoms among girls. Elevated depressive symptoms affect over 25% of adolescents. Even in the absence of full criteria for major depressive disorder (MDD), adolescent depressive symptoms are associated with considerable psychosocial and behavioral impairment and a 2-4-fold greater risk of developing MDD. Depressive symptoms also are associated with IR in adolescents and adults and predict T2D onset. Therefore, amelioration of elevated depressive symptoms in adolescent girls who are at risk for T2D has the potential to improve IR and risk for T2D in a considerable subset of youth.

Project Summary/Abstract There has been rapid escalation of type 2 diabetes (T2D) rates in adolescents. Early-onset T2D (<20y) typically shows a more aggressive course than adult-onset T2D and disproportionately affects girls from disadvantaged, racial/ethnic groups. This group of girls also is at heightened risk for depression, and depression and T2D are linked. Depressive symptoms often manifest in adolescence and are a prospective risk factor for worsening of insulin sensitivity, the major physiological precursor?in combination with deterioration of pancreatic ?-cell ca- pacity to secrete insulin?in the path to T2D. The effects of depression on poor insulin sensitivity remain even after accounting for adiposity. In theory, depressive symptoms may worsen insulin sensitivity through stress- induced behaviors (e.g., disinhibited eating, [physical inactivity], sleep disturbance) and stress-induced phys- iological causal mechanisms (e.g., hypercortisolism). The central theme of our proposal is that intervening to reduce depressive symptoms in adolescents at-risk for T2D may offer an innovative, targeted approach to ame- liorate insulin resistance and to, consequently, preserve ?-cell function and lessen T2D risk. In preliminary data from an NIH K99/R00 Award, the PI found initial evidence that a 6-week cognitive-behavioral group decreased depressive symptoms and prevented worsening of insulin sensitivity 1 year later in overweight and obese girls with moderate depressive symptoms and a family history of T2D, in comparison to a 6-week health education control group. Directly extending these findings, the aims of this R01 proposal are: 1) to assess the efficacy of a 6-week cognitive-behavioral depression group vs. a 6-week health education control group for improving insulin sensitivity and preserving ?-cell function in racially/ethnically diverse adolescent girls at-risk for T2D with mod- erate depressive symptoms over a 1-year follow-up; 2) to evaluate changes in eating, [physical activity], and sleep as behavioral explanatory mediators underlying the relationship between decreases in depressive symp- toms and improvements in insulin sensitivity and ?-cell function over 1 year and 3) to test changes in cortisol awakening response, diurnal cortisol rhythm, and total daily cortisol output as physiological mechanisms explain- ing the relationship between decreases in depressive symptoms and improvements in insulin sensitivity and ?- cell function over 1 year. We have assembled a strong, multidisciplinary team of scientists with expertise in depression, obesity, eating (PI: Lauren Shomaker, PhD), [child and adolescent insulin sensitivity and secre- tion] (Co-I: Kristen Nadeau, MD, MS), [puberty, precursors of early-onset T2D] (Co-I: Megan Kelsey, MD, MS), and statistics (Co-I: Sangeeta Rao, PhD), as well as consultation from experts on [ambulatory physical activity monitoring (Andrea Kriska, PhD, MS)], sleep medicine (Kenneth Wright Jr, PhD), [and adolescent depression (Eric Stice, PhD)]. Our long-term goal is to identify feasible, cost-effective public health solutions that have high potential for effective dissemination in communities at-risk for cardiometabolic disease and to understand the mechanisms by which alleviating psychosocial stress facilitates more positive health outcomes.

Project Summary/Abstract ? Parent Grant There has been rapid escalation of type 2 diabetes (T2D) rates in adolescents. Early-onset T2D (<20y) typically shows a more aggressive course than adult-onset T2D and disproportionately affects girls from disadvantaged, racial/ethnic groups. This group of girls also is at heightened risk for depression, and depression and T2D are linked. Depressive symptoms often manifest in adolescence and are a prospective risk factor for worsening of insulin sensitivity, the major physiological precursor?in combination with deterioration of pancreatic ?-cell capacity to secrete insulin?in the path to T2D. The effects of depression on poor insulin sensitivity remain even after accounting for adiposity. In theory, depressive symptoms may worsen insulin sensitivity through stress- induced behaviors (e.g., disinhibited eating, physical inactivity, sleep disturbance) and stress-induced physiological causal mechanisms (e.g., hypercortisolism). The central theme of our proposal is that intervening to reduce depressive symptoms in adolescents at-risk for T2D may offer an innovative, targeted approach to ameliorate insulin resistance and to, consequently, preserve ?-cell function and lessen T2D risk. In preliminary data from an NIH K99/R00 Award, the PI found initial evidence that a 6-week cognitive-behavioral group decreased depressive symptoms and prevented worsening of insulin sensitivity 1 year later in overweight and obese girls with moderate depressive symptoms and a family history of T2D, in comparison to a 6-week health education control group. Directly extending these findings, the aims of this R01 are: 1) to assess the efficacy of a 6-week cognitive-behavioral depression group vs. a 6-week health education control group for improving insulin sensitivity and preserving ?-cell function in racially/ethnically diverse adolescent girls at-risk for T2D with moderate depressive symptoms over a 1-year follow-up; 2) to evaluate changes in eating, physical activity, and sleep as behavioral explanatory mediators underlying the relationship between decreases in depressive symptoms and improvements in insulin sensitivity and ?-cell function over 1 year and 3) to test changes in cortisol awakening response, diurnal cortisol rhythm, and total daily cortisol output as physiological mechanisms explaining the relationship between decreases in depressive symptoms and improvements in insulin sensitivity and ?-cell function over 1 year. We have assembled a strong, multidisciplinary team of scientists with expertise in depression, obesity, eating (PI: Lauren Shomaker, PhD), child and adolescent insulin sensitivity and secretion (Co-I: Kristen Nadeau, MD, MS), puberty, precursors of early-onset T2D (Co-I: Megan Kelsey, MD, MS), and statistics (Co-I: Sangeeta Rao, PhD), as well as consultation from experts on ambulatory physical activity monitoring (Andrea Kriska, PhD, MS), sleep medicine (Kenneth Wright Jr, PhD), and adolescent depression (Eric Stice, PhD). Our long-term goal is to identify feasible, cost-effective public health solutions that have high potential for effective dissemination in communities at-risk for cardiometabolic disease and to understand the mechanisms by which alleviating psychosocial stress facilitates more positive health outcomes.

Project Abstract/Summary Type 2 diabetes (T2D) is a serious chronic disease that affects 28 million Americans and costs $245 billion in annual U.S. healthcare expenditures. Although previously a disease limited to adulthood, of serious concern are studies showing that rates of adolescent-onset T2D are on the rise. Adolescent-onset T2D is associated with greater health comorbidities and shorter life expectancy than adult-onset T2D. T2D is preventable by decreasing insulin resistance, the major physiological precursor to T2D. Unfortunately, standard-of-care behavioral lifestyle interventions to decrease insulin resistance through weight loss demonstrate insufficient effectiveness in adolescents, necessitating alternative approaches targeting novel risk factors. One novel modifiable risk factor is depression symptoms, a prospective risk factor for worsening insulin resistance and the onset of T2D over time, even after accounting for obesity. Depression likely promotes insulin resistance through stress-related behavior (e.g., hedonic eating, physical inactivity) and stress physiology (e.g., cortisol dysregulation, stress reactivity). In theory, mindfulness-based intervention (MBI) may be distinctively suited for adolescents at-risk for T2D through its potential to decrease depression symptoms, improve stress-related behavior and physiology, and thereby, improve insulin resistance and lessen T2D risk. To begin to test this approach, we completed a single-site, pilot randomized controlled trial (R00 HD069516) that established initial feasibility of recruitment, randomization, retention, protocol adherence, and acceptability/credibility of a 6-week group MBI program, Learning to BREATHE, among the target population. Compared to 6-week group cognitive-behavioral therapy (CBT; a standard-of-care depression intervention), MBI produced significantly greater decreases in depression symptoms and insulin resistance at 6-week/post-treatment follow-up and at 1-year follow-up in adolescents at- risk for T2D. Directly building upon our prior work, the proposed U01 study is a multisite, pilot randomized controlled trial implemented at four sites in preparation for a future multisite efficacy trial assessing the effects of 6-week group MBI, relative to another active treatment (CBT) and a didactic, health education control group (HealthEd), on depression and insulin resistance, as well as stress-related behavior and stress physiology. Specific aims of the current proposal are to: (1) Test multisite fidelity of training and implementation of 6-week group MBI, CBT, and HealthEd, to adolescents at-risk for T2D with depression symptoms; (2) Evaluate multisite feasibility and acceptability of recruitment, retention, and adherence for a protocol involving randomization to 6- week group MBI, CBT, or HealthEd with 6-week/post-treatment follow-up and 1-year follow-up; and (3) Modify intervention training/implementation and protocol procedures in preparation for a future fully-powered multisite randomized controlled efficacy trial. Completion of these aims will prepare us to apply for a UG3/UH3 efficacy trial. Ultimately, this research will inform a complementary and integrative healthcare approach to adolescents at high-risk for T2D.