The Effects of Acceptance and Commitment Therapy (ACT) Intervention on Inflammation and Stress Biomarkers: a Randomized Controlled Trial

Sampaio TP, Marçal L, Burdmann EA, Neto FL, Bernik MA. Inflammatory markers changes following acceptance-based behavioral psychotherapy in generalized anxiety disorder patients: Evidence from a randomized controlled trial

Introduction

Generalized anxiety disorder (GAD) has been associated with elevated levels of C-reactive protein (CRP) and proinflammatory cytokines. Despite robust evidence as an effective treatment for GAD, research on the effects of cognitive-behavioral therapies (CBT) in the inflammatory profile of patients with clinical anxiety has presented mixed results.

Objective

The present study aimed to investigate the effect of an acceptance-based behavior therapy (ABBT) on inflammatory biomarkers and their association with anxiety levels in GAD patients in comparison to supportive therapy as an active control.

Methods

Peripheral inflammatory biomarkers (CRP, IL-1β, IL-4, IL-6, IL-10, TNF-α) were measured in 77 GAD patients who participated in a 14-week 10-session randomized clinical trial of group ABBT (experimental, n = 37) or supportive group therapy (ST: active control group, n = 40).

Results

The concentrations of IL-1β decreased in the control group and the concentrations of IL-6 increased in the experimental group from baseline to post-treatment, whereas no difference was identified in IL-4, IL-10, TNF, or CRP. Although anxiety and depression levels decreased in both treatment conditions, no correlation with inflammation markers was found for most clinical and biological variables. A negative correlation between changes in IL-6 and IL-10 and anxiety symptom score changes was identified.

Conclusions

The present study results found that a short trial of acceptance-based behavior therapy did not change the proinflammatory profile which may be associated with GAD. Additional research is needed to evaluate the influence of other inflammation-related variables, longer periods of follow-up as well as the effect of supportive therapy on peripheral inflammatory biomarkers in GAD patients.

Mobile health (m-health) smartphone interventions for adolescents and adults with overweight or obesity

BACKGROUND

Obesity is considered to be a risk factor for various diseases, and its incidence has tripled worldwide since 1975. In addition to potentially being at risk for adverse health outcomes, people with overweight or obesity are often stigmatised. Behaviour change interventions are increasingly delivered as mobile health (m-health) interventions, using smartphone apps and wearables. They are believed to support healthy behaviours at the individual level in a low-threshold manner.

OBJECTIVES

To assess the effects of integrated smartphone applications for adolescents and adults with overweight or obesity.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, and LILACS, as well as the trials registers ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform on 2 October 2023 (date of last search for all databases). We placed no restrictions on the language of publication.

SELECTION CRITERIA

Participants were adolescents and adults with overweight or obesity. Eligible interventions were integrated smartphone apps using at least two behaviour change techniques. The intervention could target physical activity, cardiorespiratory fitness, weight loss, healthy diet, or self-efficacy. Comparators included no or minimal intervention (NMI), a different smartphone app, personal coaching, or usual care. Eligible studies were randomised controlled trials of any duration with a follow-up of at least three months.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the RoB 2 tool. Important outcomes were physical activity, body mass index (BMI) and weight, health-related quality of life, self-efficacy, well-being, change in dietary behaviour, and adverse events. We focused on presenting studies with medium- (6 to < 12 months) and long-term (≥ 12 months) outcomes in our summary of findings table, following recommendations in the core outcome set for behavioural weight management interventions.

MAIN RESULTS

We included 18 studies with 2703 participants. Interventions lasted from 2 to 24 months. The mean BMI in adults ranged from 27 to 50, and the median BMI z-score in adolescents ranged from 2.2 to 2.5. Smartphone app versus no or minimal intervention Thirteen studies compared a smartphone app versus NMI in adults; no studies were available for adolescents. The comparator comprised minimal health advice, handouts, food diaries, smartphone apps unrelated to weight loss, and waiting list. Measures of physical activity: at 12 months' follow-up, a smartphone app compared to NMI probably reduces moderate to vigorous physical activity (MVPA) slightly (mean difference (MD) -28.9 min/week (95% confidence interval (CI) -85.9 to 28; 1 study, 650 participants; moderate-certainty evidence)). We are very uncertain about the results of estimated energy expenditure and cardiorespiratory fitness at eight months' follow-up. A smartphone app compared with NMI probably results in little to no difference in changes in total activity time at 12 months' follow-up and leisure time physical activity at 24 months' follow-up. Anthropometric measures: a smartphone app compared with NMI may reduce BMI (MD of BMI change -2.6 kg/m2, 95% CI -6 to 0.8; 2 studies, 146 participants; very low-certainty evidence) at six to eight months' follow-up, but the evidence is very uncertain. At 12 months' follow-up, a smartphone app probably resulted in little to no difference in BMI change (MD -0.1 kg/m2, 95% CI -0.4 to 0.3; 1 study; 650 participants; moderate-certainty evidence). A smartphone app compared with NMI may result in little to no difference in body weight change (MD -2.5 kg, 95% CI -6.8 to 1.7; 3 studies, 1044 participants; low-certainty evidence) at 12 months' follow-up. At 24 months' follow-up, a smartphone app probably resulted in little to no difference in body weight change (MD 0.7 kg, 95% CI -1.2 to 2.6; 1 study, 245 participants; moderate-certainty evidence). A smartphone app compared with NMI may result in little to no difference in self-efficacy for a physical activity score at eight months' follow-up, but the results are very uncertain. A smartphone app probably results in little to no difference in quality of life and well-being at 12 months (moderate-certainty evidence) and in little to no difference in various measures used to inform dietary behaviour at 12 and 24 months' follow-up. We are very uncertain about adverse events, which were only reported narratively in two studies (very low-certainty evidence). Smartphone app versus another smartphone app Two studies compared different versions of the same app in adults, showing no or minimal differences in outcomes. One study in adults compared two different apps (calorie counting versus ketogenic diet) and suggested a slight reduction in body weight at six months in favour of the ketogenic diet app. No studies were available for adolescents. Smartphone app versus personal coaching Only one study compared a smartphone app with personal coaching in adults, presenting data at three months. Two studies compared these interventions in adolescents. A smartphone app resulted in little to no difference in BMI z-score compared to personal coaching at six months' follow-up (MD 0, 95% CI -0.2 to 0.2; 1 study; 107 participants). Smartphone app versus usual care Only one study compared an app with usual care in adults but only reported data at three months on participant satisfaction. No studies were available for adolescents. We identified 34 ongoing studies.

AUTHORS' CONCLUSIONS

The available evidence is limited and does not demonstrate a clear benefit of smartphone applications as interventions for adolescents or adults with overweight or obesity. While the number of studies is growing, the evidence remains incomplete due to the high variability of the apps' features, content and components, which complicates direct comparisons and assessment of their effectiveness. Comparisons with either no or minimal intervention or personal coaching show minor effects, which are mostly not clinically significant. Minimal data for adolescents also warrants further research. Evidence is also scarce for low- and middle-income countries as well as for people with different socio-economic and cultural backgrounds. The 34 ongoing studies suggest sustained interest in the topic, with new evidence expected to emerge within the next two years. In practice, clinicians and healthcare practitioners should carefully consider the potential benefits, limitations, and evolving research when recommending smartphone apps to adolescents and adults with overweight or obesity.

Inflammatory biomarkers link perceived stress with metabolic dysregulation

Objective

Perceived stress has been identified as a risk factor for metabolic syndrome. However, the intermediate pathways underlying this relationship are not well understood. Inflammatory responses may be one process by which stress leads to metabolic dysregulation. Prior work has shown that chronic stress is associated with elevated systemic inflammation and that altered inflammatory activity contributes to the pathogenesis of metabolic syndrome. The current analyses tested this hypothesis by examining inflammation as a pathway by which perceived stress affects metabolic health.

Methods

Data from the Midlife in the United States Study (MIDUS) (N = 648; Mean age = 52.3) provided measures of perceived stress, inflammatory biomarkers [C-reactive protein (CRP), interleukin-6 (IL-6), E-selectin, fibrinogen, intracellular adhesion molecule-1 (ICAM-1)] and metabolic health markers. Confirmatory factor analysis (CFA) was used to confirm the fit of a hierarchical model of metabolic syndrome in our sample. Structural equation modeling (SEM) was used to test the assumption that inflammation mediates the association between perceived stress and the latent factor representing metabolic syndrome.

Results

The CFA of metabolic syndrome demonstrated excellent goodness of fit to our sample [CFI = 0.97, TLI = 0.95, RMSEA = 0.06, SMSR = 0.05]. Mediation analysis with SEM revealed that the indirect pathway linking stress to metabolic dysregulation through inflammation was significant [B = 0.08, SE = 0.01, z = 3.69, p < .001, 95% confidence interval CI (0.04, 0.13)].

Conclusions

These results suggest that inflammatory biomarkers are a viable explanatory pathway for the relationship between perceived stress and metabolic health consequences. Interventions that target psychosocial stress may serve as cost-effective and accessible treatment options for mitigating inflammatory health risks.

Comparative efficacy of psychological interventions on immune biomarkers: A systematic review and network meta-analysis (NMA)

Psychological interventions are viable, cost-effective strategies for improving clinical and psychological impact of inflammation-related conditions. However, their efficacy on immune system function remains controversial. We performed a systematic review and frequentist random-effects network meta-analysis of randomised controlled trials (RCTs) assessing the effects of psychological interventions, against a control condition, on biomarkers of innate and adaptive immunity in adults. PubMed, Scopus, PsycInfo, and Web of Science were searched from inception up to Oct 17, 2022. Cohen's d at 95% confidence interval (CI) was calculated to assess the effect sizes of each class of intervention against active control conditions at post-treatment. The study was registered in PROSPERO (CRD42022325508). Of the 5024 articles retrieved, we included 104 RCTs reporting on 7820 participants. Analyses were based on 13 types of clinical interventions. Compared with the control conditions, cognitive therapy (d =  - 0.95, 95% CI: -1.64 to - 0.27), lifestyle (d =  - 0.51, 95% CI: -0.99 to - 0.02), and mindfulness-based (d =  - 0.38, 95% CI: -0.66 to - 0.09) interventions were associated with post-treatment reduction of proinflammatory cytokines and markers. Mindfulness-based interventions were also significantly associated with post-treatment increase in anti-inflammatory cytokines (d = 0.69, 95% CI: 0.09 to 1.30), while cognitive therapy was associated also with post-treatment increase in white blood cell count (d = 1.89, 95% CI: 0.05 to 3.74). Results on natural killer cells activity were non-significant. Grade of evidence was moderate for mindfulness and low-to-moderate for cognitive therapy and lifestyle interventions; however, substantial overall heterogeneity was detected in most of the analyses.

Only Small Effects of Mindfulness-Based Interventions on Biomarker Levels of Inflammation and Stress: A Preregistered Systematic Review and Two Three-Level Meta-Analyses

Mindfulness-based interventions (MBIs) have a positive effect on biomarkers of inflammation and stress in patients with psychiatric disorders and physical illnesses. Regarding subclinical populations, results are less clear. The present meta-analysis addressed the effects of MBIs on biomarkers in psychiatric populations and among healthy, stressed, and at-risk populations. All available biomarker data were investigated with a comprehensive approach, using two three-level meta-analyses. Pre-post changes in biomarker levels within treatment groups (k = 40 studies, total N = 1441) and treatment effects compared to control group effects, using only RCT data (k = 32, total N = 2880), were of similar magnitude, Hedges g = -0.15 (95% CI = [-0.23, -0.06], p < 0.001) and g = -0.11 (95% CI = [-0.23, 0.001], p = 0.053). Effects increased in magnitude when including available follow-up data but did not differ between type of sample, MBI, biomarker, and control group or duration of the MBI. This suggests that MBIs may ameliorate biomarker levels in both psychiatric and subclinical populations to a small extent. However, low study quality and evidence of publication bias may have impacted on the results. More large and preregistered studies are still needed in this field of research.

Intuitive Eating Intervention and Diet Quality in Adults: A Systematic Literature Review

INTRODUCTION

Intuitive eating interventions aim to improve individual health and promote sustainable changes to one's relationship with food. However, there is no evidence-based consensus on the impact of intuitive eating interventions on diet quality. This systematic review aimed to investigate intuitive eating interventions and their impact on diet quality.

METHOD

PubMed, Embase, CINAHL, PsycInfo, and Cochrane databases were systematically searched to October 2021 for studies reporting interventions that encompassed the principles of intuitive eating and measured diet quality. Other health outcomes were used for secondary analysis. Findings were synthesized narratively.

RESULTS

Seventeen papers reporting 14 intervention studies (n = 3,960) were included in the review. All studies found a positive or neutral effect on diet quality following an intuitive eating intervention. A favorable change in eating behavior following these interventions was also observed.

DISCUSSION

Intuitive eating promotes an attunement to the body, which aids in improving diet quality because of increased awareness of physiological cues. The reduction of emotional and binge eating may also increase diet quality.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Findings from the current review suggest that intuitive eating interventions are most effective face-to-face, in a group setting, and sustained for at least 3 months.

Chronic Stress Is Associated with Reduced Mindful Acceptance Skills but Not with Mindful Attention Monitoring: A Cross-Sectional Study

Mindfulness-based interventions (MBIs) are effective in reducing chronic stress, but their therapeutic mechanisms are unclear. One possibility is that MBIs act by re-training attention monitoring and acceptance skills that have been impaired by chronic stress exposure. However, little research has investigated the association between chronic stress, monitoring, and acceptance. In this cross-sectional study we hypothesised observing correlations between stress, and (impaired) monitoring and acceptance. Moreover, we exploratively compared the magnitude of the correlations between chronic stress and four acceptance measures. Finally, we explored whether the association between stress and monitoring is moderated by acceptance. Eighty-five adults participated in the study and completed self-reported chronic stress and acceptance questionnaires and a mindful attention behavioural task. The results revealed that chronic stress was associated with reduced acceptance (all ps < 0.01) but not with monitoring. Exploratory analyses revealed no differences in the magnitude of the correlations between stress and each acceptance measure, except for the combined facets of mindfulness acceptance subscales and nonreactivity subscale (p = 0.023). Further analyses revealed a significant negative association between stress and the interaction between acceptance and the target detection component of monitoring (p = 0.044). Surprisingly, these results show that stress is associated with reduced monitoring at higher levels of acceptance. Theory-driven intervention studies are warranted to complement our results.

New generation psychological treatments in chronic pain

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called "third wave" CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.