Indirect Effects of a Cognitive-Behavioral Intervention on Adolescent Weight and Insulin Resistance Through Decreasing Depression in a Randomized Controlled Trial

Clinical improvement of DM1 patients reflected by reversal of disease-induced gene expression in blood

BACKGROUND

Myotonic dystrophy type 1 (DM1) is an incurable multisystem disease caused by a CTG-repeat expansion in the DM1 protein kinase (DMPK) gene. The OPTIMISTIC clinical trial demonstrated positive and heterogenous effects of cognitive behavioral therapy (CBT) on the capacity for activity and social participations in DM1 patients. Through a process of reverse engineering, this study aims to identify druggable molecular biomarkers associated with the clinical improvement in the OPTIMISTIC cohort.

METHODS

Based on full blood samples collected during OPTIMISTIC, we performed paired mRNA sequencing for 27 patients before and after the CBT intervention. Linear mixed effect models were used to identify biomarkers associated with the disease-causing CTG expansion and the mean clinical improvement across all clinical outcome measures.

RESULTS

We identified 608 genes for which their expression was significantly associated with the CTG-repeat expansion, as well as 1176 genes significantly associated with the average clinical response towards the intervention. Remarkably, all 97 genes associated with both returned to more normal levels in patients who benefited the most from CBT. This main finding has been replicated based on an external dataset of mRNA data of DM1 patients and controls, singling these genes out as candidate biomarkers for therapy response. Among these candidate genes were DNAJB12, HDAC5, and TRIM8, each belonging to a protein family that is being studied in the context of neurological disorders or muscular dystrophies. Across the different gene sets, gene pathway enrichment analysis revealed disease-relevant impaired signaling in, among others, insulin-, metabolism-, and immune-related pathways. Furthermore, evidence for shared dysregulations with another neuromuscular disease, Duchenne muscular dystrophy, was found, suggesting a partial overlap in blood-based gene dysregulation.

CONCLUSIONS

DM1-relevant disease signatures can be identified on a molecular level in peripheral blood, opening new avenues for drug discovery and therapy efficacy assessments.

The Relationship Between Anxiety, Coping, and Disordered-Eating Attitudes in Adolescent Military-Dependents at High-Risk for Excess Weight Gain

Adolescent military-dependents are an understudied population who face unique stressors due to their parents' careers. Research suggests that adolescent military-dependents report more anxiety and disordered-eating than their civilian counterparts. While anxiety symptoms predict the onset and worsening of disordered-eating attitudes, the mechanisms underlying this relationship remain unclear. One factor that may underlie this relationship, and be particularly relevant for military-dependent youth, is coping. Therefore, we examined adolescent military-dependents (N=136; 14.5±1.5 years; 59.6% female; BMI-z: 1.9±0.4) who were at-risk for adult obesity and binge-eating disorder due to an age- and sex-adjusted BMI ≥ 85th percentile and loss-of-control eating and/or elevated anxiety. Participants completed an interview assessing disordered-eating attitudes and questionnaires on anxiety symptoms and coping strategies at a single time point. Bootstrapping models were conducted to examine the indirect paths between anxiety symptoms and disordered-eating attitudes through five coping subscales (aggression, distraction, endurance, self-distraction, and stress-recognition). Adjusting for relevant covariates, no significant indirect paths through the coping subscales (ps > .05) were found in any models. General coping, non-specific to eating, may not be a pathway between anxiety symptoms and disordered-eating attitudes among adolescents. Future research should examine other potential mediators of this relationship.

Examining cognitive-behavioral therapy change mechanisms for decreasing depression, weight, and insulin resistance in adolescent girls at risk for type 2 diabetes

OBJECTIVE

Depression in adolescence is linked to risk for type 2 diabetes (T2D). In this secondary data analysis of a randomized controlled trial comparing cognitive-behavioral therapy (CBT) to a control program to ameliorate insulin resistance via reducing depression symptoms, we examine which CBT change mechanisms (e.g., behavioral activation, cognitive restructuring) contributed to decreased depression and subsequent improvements in body mass index (BMI), percent body fat, and insulin resistance.

METHODS

Girls 12-17y with overweight/obesity and family history of T2D were randomized to six-week group CBT (n = 61) or health education (HealthEd; n = 58). At baseline and post-treatment, adolescents completed questionnaires assessing activities, thoughts, and depression symptoms. At baseline, post-treatment, and one-year, BMI was calculated and insulin outcomes were derived from two-hour oral glucose tolerance testing. At baseline and one-year, percent body fat was assessed with dual-energy x-ray absorptiometry. Indirect effects of CBT components were tested on one-year changes in BMI, percent body fat, and insulin indices through decreases in depression symptoms during treatment. Intervention was tested as a moderator.

RESULTS

In CBT, but not HealthEd, there was an indirect effect of increased physical activity during treatment on decreased one-year BMI via reductions in depression symptoms during treatment. Also, there were conditional indirect effects in CBT of increased pleasantness of physical and social activity during treatment on decreased one-year BMI via decreased depression symptoms during treatment.

CONCLUSION

Behavioral activation may be a useful intervention to decrease depression and reduce excess weight gain in the targeted prevention of T2D in at-risk adolescent girls. NCT01425905, clinicaltrials.gov.

Weight Management in Adolescents with Polycystic Ovary Syndrome

PURPOSE OF REVIEW

Polycystic ovary syndrome (PCOS) is a common condition that clinically presents during adolescence. PCOS is associated with increased rates of overweight and obesity, as well as higher rates of metabolic disease, especially type 2 diabetes. Weight loss decreases PCOS symptoms and risk for metabolic disease. The goal of this review is to evaluate recent studies describing the hormonal, metabolic, and weight effects of different weight loss strategies: dietary, physical activity, pharmacotherapy, bariatric surgery, mood modification, and sleep.

RECENT FINDINGS

Calorie restriction continues to be supported as the primary nutrition intervention to achieve weight loss in individuals with PCOS, and a dietary macronutrient composition with lower compared to higher glycemic carbohydrates may be more effective. There is limited data that vitamins, nutraceuticals, and probiotics may improve hormonal and metabolic outcomes. Most types of physical activity are effective in improving outcomes in PCOS and lowering weight. Whereas there are promising data on anti-obesity medications such as glucagon-like peptide-1 receptor agonists in adults with PCOS and adolescents with obesity, further work is needed to know if these therapies are effective in youth with PCOS. Research is lacking on the effectiveness of other anti-obesity medications in PCOS. Bariatric surgery is especially promising for decreasing weight in adults and youth, and reversing type 2 diabetes in youth, though PCOS data are lacking. Treatment of depression in adolescents with insulin resistance and women with PCOS is associated with improved weight loss. Adolescents with PCOS and obesity may have greater sleep-related risks including circadian misalignment and obstructive sleep apnea, interventions for which have not yet been conducted. Clinical trials on weight loss strategies in adolescents with PCOS remain limited, with most information inferred from studies in women with PCOS or adolescents with obesity. However, there are multiple options to optimize weight loss in dietary, activity, pharmacotherapy, bariatric surgery, mood modification, and sleep domains.

Cognitive Behavioral Therapy and Mindfulness-Based Cognitive Therapy in Children and Adolescents with Type 2 Diabetes

PURPOSE OF REVIEW

Among adults with type 2 diabetes (T2D), cognitive behavioral therapy (CBT), acceptance and commitment therapy, and mindfulness interventions have demonstrated improvement in depression, anxiety, and glycemic control. We assessed whether these treatment modalities have shown usefulness in adolescents with T2D or at risk for T2D.

RECENT FINDINGS

Data are limited on the use of the abovementioned therapeutic interventions and include only adolescent girls at risk for T2D. CBT was as useful as health education sessions. At 1 year, greater decreases in depression, insulin resistance, and BMI were observed in girls randomized to mindfulness compared with CBT groups. Given the positive outcome of mindfulness intervention in adults and in adolescent girls at risk for T2D, future studies should involve males at risk for T2D, and adolescents diagnosed with T2D. Longer interventions and booster meetings for maintenance should be studied.

Potential role of insulin on the pathogenesis of depression

The regulation of insulin on depression and depression-like behaviour has been widely reported. Insulin and activation of its receptor can promote learning and memory, affect the hypothalamic-pituitary-adrenal axis (HPA) balance, regulate the secretion of neurotrophic factors and neurotransmitters, interact with gastrointestinal microbiome, exert neuroprotective effects and have an impact on depression. However, the role of insulin on depression remains largely unclear. Therefore, in this review, we summarized the potential role of insulin on depression. It may provide new insight for clarifying role of insulin on the pathogenesis of depression.