Exercise as Medicine for People with a Substance Use Disorder: An ACSM Call to Action Statement.

ABSTRACT: Over 20 million Americans are living with a substance use disorder (SUD) and nearly 100,000 die annually from drug overdoses, with a majority involving an opioid. Many people with SUD have co-occurring chronic pain and/or a mental health disorder. Exercise is a frontline treatment for chronic pain and is an effective strategy for reducing depression and anxiety and improving overall mental health. Several studies have shown that exercise improves SUD-related outcomes including abstinence; however, there is limited large-scale randomized clinical trial evidence to inform integration of exercise into practice. In this Call to Action, we aim to raise awareness of the specific issues that should be addressed to advance exercise as medicine in people with SUD including the challenges of co-occurring chronic pain, mental illness, and cardiopulmonary health conditions. In addition, specialized training for exercise professionals and other support staff should be provided on these issues, as well as on the multiple dimensions of stigma that can impair engagement in treatment and overall recovery in people with SUD.

POSITION STATEMENT: Pass the RESTORE (Re-entry Support Through Opportunities for Resources and Essentials) Act.

Under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), current federal policy mandates a lifetime ban for individuals with a past felony drug conviction from receiving Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) benefits. Denying nutritional and financial assistance to individuals with a past felony conviction will widen existing structural health inequities, set back individuals' successful re-entry into society, and contribute to recidivism and poorer health outcomes. Therefore, the Society of Behavioral Medicine supports the RESTORE ACT (Re-Entry Support Through Opportunities for Resources and Essentials Act), which would repeal the lifetime ban on receiving SNAP and TANF benefits for individuals convicted of a drug felony.

Current US law bans people who have been convicted of felony drug crime from participating in nutritional and financial assistance programs (i.e. Supplemental Nutrition Assistance Program [SNAP] and Temporary Assistance for Needy Families [TANF]). By not allowing people who have been convicted of a drug felony to access these programs, this law risks worsening health outcomes and perpetuating existing health disparities. The Society of Behavioral Medicine supports the RESTORE Act (Re-Entry Support Through Opportunities for Resources and Essentials Act), which would end the federal ban and allow all income-eligible people to access SNAP and TANF benefits.

Barriers, perceived benefits and preferences to exercise in adults with an opioid use disorder in the U.S.

Introduction: Over 10 million Americans misuse opioids and more than 5 million have been diagnosed with an opioid use disorder (OUD). In 2021, over 100,000 Americans died of a drug overdose and more than 75% of these deaths involved an opioid. Exercise has been shown to increase abstinence and decrease anxiety and depression in people with a substance use disorder. However, only a few small trials have focused on persons with OUD who often experience additional challenges including chronic pain, mental health disorders and cardio-metabolic abnormalities. Methods: We aimed to describe the barriers, perceived benefits and preferences to exercise in adults with OUD in residential treatment in the U.S. as part of a larger study. We conducted 33 individually administered, semi-structured interviews and transcribed audiotapes verbatim, conducted coding and thematic analysis using NVivo v12 software (QSR International Inc.). Results: Our sample had nearly equal representation of males and females and, was predominantly Caucasian (88%) with a mean of age of 34.5 (s.d. 7.5) years old. Participants stated that exercise helps to reduce drug cravings, anxiety, depression and pain and improve mood, physical health and build "normalcy". Barriers included lack of time, access to resources, fear of poor health and triggering pain. Participants preferred moderate intensity exercise 3 times/week and 30-60 min sessions. Conclusions: Our findings indicate that adults with OUD believe exercise is a valuable tool to use in their recovery but they encounter several barriers. Many barriers, however, could be overcome with structured programs offered by residential treatment centers.

Neural correlates of inhibitory control in severe class III compared with class I/II obesity using a sample of endometrial cancer survivors seeking weight loss.

OBJECTIVE: No prior studies have evaluated inhibitory control in people with severe class III compared with class I/II obesity. Thus, the study aim was to evaluate inhibitory control and neural correlates of response inhibition by obesity class using a sample of endometrial cancer (EC) survivors with obesity, who have a higher risk of overall but not cancer-specific mortality. METHODS: Forty-eight stage I EC survivors with obesity (class I/II: n = 21; class III: n = 27) seeking weight loss in a lifestyle intervention at baseline completed a stop signal task during functional magnetic resonance imaging. RESULTS: It was found that participants with class III obesity had a longer stop signal reaction time (mean [SD], 278.8 [51.3] vs. 251.5 [34.0] milliseconds, p < 0.01) compared with those with class I/II obesity, indicating that patients with EC with severe obesity had greater impulsivity and poorer inhibitory control. Results also showed increased activation in the thalamus and superior frontal gyrus for the incorrect versus correct inhibition contrast in class III but not class I/II obesity (whole brain cluster corrected, p < 0.05). CONCLUSIONS: These results provide novel insights into inhibitory control and corresponding neural correlates in severe versus less severe classes of obesity and highlight the importance of targeting inhibitory control processes in weight-loss interventions, particularly for people with severe obesity and greater impulsivity.

Food Insecurity and Nutritional Challenges in Adolescent and Young Adult Cancer Survivors in the U.S.A.: A Narrative Review and Call to Action.

Advancements in cancer treatments over the past several decades have led to improved cancer survival in adolescents and young adults (AYAs, ages 15-39 years). However, AYA cancer survivors are at an increased risk for "late effects", including cardiovascular, pulmonary and bone diseases as well as fatigue, infertility and secondary cancers. The treatments for cancer may also alter taste, lead to nutritional deficiencies and increase financial burdens that, when taken together, may increase the risk of food and nutrition security in AYA cancer survivors. Furthermore, although AYAs are often merged together in cancer survivorship studies, adolescents and young adults have distinct developmental, psychosocial and pathophysiological differences that may modify their risk of nutritional challenges. In this narrative review and "Call to Action", rationale is provided for why there is a need to better understand nutritional challenges and food insecurity in AYA cancer survivors as a special population. Then, recommendations for next steps to advance knowledge and policy in this field are provided. In particular, integrating screening for food and nutrition insecurity and enhancing awareness of existing resources (e.g., the Supplemental Nutrition Assistance Program, SNAP) might help AYA cancer survivors combat nutritional deficiencies and reduce late effects while improving their overall survival and quality of life.

Interplay of Immunosuppression and Immunotherapy Among Patients With Cancer and COVID-19.

Importance: Cytokine storm due to COVID-19 can cause high morbidity and mortality and may be more common in patients with cancer treated with immunotherapy (IO) due to immune system activation. Objective: To determine the association of baseline immunosuppression and/or IO-based therapies with COVID-19 severity and cytokine storm in patients with cancer. Design, Setting, and Participants: This registry-based retrospective cohort study included 12 046 patients reported to the COVID-19 and Cancer Consortium (CCC19) registry from March 2020 to May 2022. The CCC19 registry is a centralized international multi-institutional registry of patients with COVID-19 with a current or past diagnosis of cancer. Records analyzed included patients with active or previous cancer who had a laboratory-confirmed infection with SARS-CoV-2 by polymerase chain reaction and/or serologic findings. Exposures: Immunosuppression due to therapy; systemic anticancer therapy (IO or non-IO). Main Outcomes and Measures: The primary outcome was a 5-level ordinal scale of COVID-19 severity: no complications; hospitalized without requiring oxygen; hospitalized and required oxygen; intensive care unit admission and/or mechanical ventilation; death. The secondary outcome was the occurrence of cytokine storm. Results: The median age of the entire cohort was 65 years (interquartile range [IQR], 54-74) years and 6359 patients were female (52.8%) and 6598 (54.8%) were non-Hispanic White. A total of 599 (5.0%) patients received IO, whereas 4327 (35.9%) received non-IO systemic anticancer therapies, and 7120 (59.1%) did not receive any antineoplastic regimen within 3 months prior to COVID-19 diagnosis. Although no difference in COVID-19 severity and cytokine storm was found in the IO group compared with the untreated group in the total cohort (adjusted odds ratio [aOR], 0.80; 95% CI, 0.56-1.13, and aOR, 0.89; 95% CI, 0.41-1.93, respectively), patients with baseline immunosuppression treated with IO (vs untreated) had worse COVID-19 severity and cytokine storm (aOR, 3.33; 95% CI, 1.38-8.01, and aOR, 4.41; 95% CI, 1.71-11.38, respectively). Patients with immunosuppression receiving non-IO therapies (vs untreated) also had worse COVID-19 severity (aOR, 1.79; 95% CI, 1.36-2.35) and cytokine storm (aOR, 2.32; 95% CI, 1.42-3.79). Conclusions and Relevance: This cohort study found that in patients with cancer and COVID-19, administration of systemic anticancer therapies, especially IO, in the context of baseline immunosuppression was associated with severe clinical outcomes and the development of cytokine storm. Trial Registration: ClinicalTrials.gov Identifier: NCT04354701.

Improving Surveillance and Epidemic Response in Ohio Childcare Settings.

At the start of the Coronavirus Disease of 2019 (COVID-19) pandemic, the risk of cases in childcare programs was unknown. Thus, a rapid-response research approach was launched in Ohio childcare settings. Passive surveillance data from a state-operated incident reporting system were evaluated to estimate the number of COVID-19 cases from 15 August 2020 to 1 January 2021. Additionally, active surveillance with self-administered reverse transcriptase-polymerase chain reaction (RT-PCR) tests were conducted among staff at 46 childcare programs. Finally, six zoom-based focus groups with program administrators were used to gain feedback. Staff and children in childcare settings contributed 0.38% and 0.15% of the COVID-19 cases in Ohio during this timeframe, respectively. RT-PCR testing identified 3 unrecognized cases (0.88% of tests), and all occurred when the statewide positivity rate was >5%. Focus groups revealed that access to affordable cleaning supplies, masks, and reliable staffing were critical. Perhaps most importantly, we conclude that expanding the incident reporting system to include a childcare census would allow for the tracking of future health problems with highly valuable incidence rate estimations.

A randomized controlled trial of the effect of supervised exercise on functional outcomes in older African American and non-Hispanic White breast cancer survivors: Are there racial differences in the effects of exercise on functional outcomes?

BACKGROUND: The objective of this study was to test the hypothesis that exercise would be more effective than a support group plus Fitbit (SG+Fitbit) program in improving functional outcomes in older breast cancer survivors (BCSs) and that race would moderate the exercise effect on outcomes. METHODS: Older African American (AA) and non-Hispanic White (NHW) BCSs were purposively recruited and enrolled into the 52-week randomized controlled trial. The interventions included 20 weeks of supervised moderate-intensity aerobic and resistance training followed by 32 weeks of unsupervised exercise called IMPROVE (n = 108) and a 20-week SG+Fitbit program followed by 32 weeks of unsupervised activity (n = 105). Study outcomes were assessed at 20 and 52 weeks. The primary outcome was the change in Short Physical Performance Battery (SPPB) scores 20 weeks from the baseline between arms. Secondary outcomes included change in the 6-Minute Walk Test (6MWT) in meters 20 weeks from the baseline between arms. General linear regression and multivariable logistic regression analyses were used. RESULTS: The mean age was 71.9 years (SD, 5.9 years), and 44% were AA. SPPB scores did not differ between arms (adjusted difference in mean change, 0.13; 95% CI, -0.28 to 0.55; P = .53). However, the exercise arm (vs the SG+Fitbit arm) improved on the 6MWT (21.6 m; 95% CI, 2.5-40.6 m; P = .03). Race moderated the exercise effect on the 6MWT (adjusted interaction effect, 43.3 m; 95% CI, 6.3-80.2 m; P = .02); this implied that the change in the adjusted mean for the 6MWT at 20 weeks from the baseline was 43.3 m higher in AA exercise participants versus NHW exercise participants. CONCLUSIONS: Combined aerobic and resistance exercise appears to improve physical performance in older BCSs, and the exercise effect might be moderated by race, with AAs appearing to derive larger benefits in comparison with NHWs. Larger studies are warranted to confirm the study findings.

Physical Activity and Sleep Measures Using a Fitness Tracking Device during Hematopoietic Cell Transplantation: A Pilot Study.

Patients undergoing hematopoietic cell transplantation (HCT) experience decline in their physical activity during their transplant admission. There is limited experience with prospective monitoring of transplant recipients. We therefore measured physical activity and sleep patterns of subjects undergoing autologous and allogeneic HCT. Eighty-three patients were consented for this study. Sixty-three patients competed the study and had their physical activity prospectively assessed using the fitness-tracking device Fitbit HR. Outcomes included adherence, physical activity, readmission, hematopoietic engraftment, and 100-day survival. Sixty percent of patients (n = 37) underwent autologous HCT, and 40% (n = 26) underwent allogenic HCT. Both groups had a comparable number of steps at admission to the hospital. The number of daily steps during the study period was lower in the allogeneic group (2159 versus 3008, P = .07), as was the minimum number of steps recorded over the transplant admission (allogeneic HCT = 395 versus autologous HCT = 848, P = .01). Patients undergoing allogeneic HCT were less active on the day before discharge (1956 steps versus 3183 steps, P = .08). In multivariate analysis, physical activity was not associated with HCT-related outcomes. Patients undergoing HCT experience significant decline in their physical activity during their transplant admission that does not recover by the time of discharge. This effect can be objectively measured using fitness tracking devices.

IMPROVE, a community-based exercise intervention versus support group to improve functional and health outcomes among older African American and Non-Hispanic White breast cancer survivors from diverse socioeconomic backgrounds: Recruitment strategies and baseline characteristics.

BACKGROUND: Behavioral intervention studies in older breast cancer survivors, particularly older African American (AA) and socioeconomic status-disadvantaged breast cancer survivors, are lacking. To inform future studies, the authors examined recruitment strategies in older breast cancer survivors who participated in an exercise intervention study. METHODS: IMPROVE is a randomized trial designed to evaluate a group-based exercise intervention versus a support group (ClinicalTrials.gov identifier, NCT02763228). Participants were aged ≥65 years who had survived stage I through III breast cancer and were within 5 years of treatment completion. Participants were recruited through multiple approaches, including peripheral, linguistic, and constituent-involving strategies that incorporated the identification of potentially eligible patients from 3 local hospitals and from State of Ohio registries and through direct clinician and community organization referrals. RESULTS: Between October 2016 and November 2019, 7487 patients were screened, 4790 were potentially eligible, and 213 were randomized into the study. The eligible:randomization rates were 4.4% overall and 84%, 8%, and 2% for recruitment using direct referrals, hospital registries, and state registries, respectively. The median age of the randomized cohort was 70 years (range, 65-88 years) and included 44% AA and 44% socioeconomic status-disadvantaged breast cancer survivors. Compared with all registry-eligible patients, directly referred-eligible patients were more likely to be AA versus Non-Hispanic White (41% vs 19%; P = .006), to be contacted successfully (100% vs 33%; P < .0001), and to accept study participation (88% vs 16%; P < .0001). CONCLUSIONS: Direct referrals appeared to be the most efficient strategy for recruiting AA survivors. Behavioral intervention studies seeking to target older AA and socioeconomic status-disadvantaged breast cancer survivors should include strategies that foster direct referrals to study participation.

Insights to the neural response to food cues in class III compared with class I and II obese adults using a sample of endometrial cancer survivors seeking weight loss.

BACKGROUND: The rates of severe or Class III obesity (BMI ≥ 40.0 kg/m2) and endometrial cancer (EC) incidence and mortality have been increasing significantly in the United States. Adults with severe obesity are more likely to die and women with severe obesity have a higher risk of EC development and mortality than those with Class I/II obesity (BMI: 30-<40 kg/m2). However, no prior studies have evaluated the neural response to food cues by obesity severity/class in adults with or without cancer. METHODS: We conducted a functional magnetic resonance imaging visual food cue task in 85 obese Stage I EC survivors who were seeking weight loss in a lifestyle intervention at baseline. We evaluated the neural response to high-calorie vs. non-food images after an overnight fast (fasted state) and after eating a standardized meal (fed state), and grouped patients by obesity class (Class I/II: n = 38; Class III: n = 47). RESULTS: In the fasted state, we found increased activation in several regions including the dorsolateral prefrontal cortex (DLPFC) in Class III and Class I/II patients (whole brain cluster corrected (WBCC), p < 0.05), which was significantly higher in Class III vs. Class I/II (p < 0.05). We found decreased activation in the insula in the fasted state, which was significantly lower in Class I/II vs. Class III (p = 0.03). In the fed state, we found increased activation in the DLPFC in Class III and Class I/II (WBCC, p < 0.05). The increased activation in cognitive control/inhibition regions (DLPFC) is consistent with the summative literature; however, the decreased activation in taste information processing regions (insula) was unexpected. CONCLUSIONS: Our results provide novel insights on food cue response between different classes of obesity and highlight the importance of targeting the DLPFC in weight loss interventions, particularly in severely obese patients. Additional studies examining food-related neural circuitry between different classes of obesity are needed.

IMPROVE, a community-based exercise intervention versus support group to improve functional and health outcomes among older African American and non-Hispanic White breast cancer survivors from diverse socioeconomic backgrounds: Rationale, design and methods.

BACKGROUND: African Americans (AA) and socioeconomic status (SES) disadvantaged older breast cancer survivors (BCS) are more likely to experience poor functional and health outcomes. However, few studies have evaluated the putative beneficial effects of exercise on these outcomes in older racial minority and SES-disadvantaged BCS. METHODS: This is a mixed-methods study that includes a randomized-controlled trial, "IMPROVE", to evaluate a group-based exercise intervention compared to a support group program in older BCS, followed by post-intervention semi-structured interviews to evaluate the intervention. The trial aims to recruit 220 BCS with 55 in each of four strata defined by race (AA versus Non-Hispanic Whites) and SES (disadvantaged vs. non-disadvantaged). Participants are ≥65 years old and within five years of treatment completion for stage I-III breast cancer. Participants are randomized to a 52-week, three sessions/week, one-hour/session, moderate intensity aerobic and resistance group exercise intervention, (n = 110) or a 52-week, one hour/week, support group intervention [attention-control arm], (n = 110). The first 20 weeks of both programs are supervised and the last 32 weeks, unsupervised. The primary outcome is the change in Short Physical Performance Battery (SPPB) Scores at 20 weeks from baseline, between the two arms. Secondary outcomes include change in SPPB scores at 52 weeks, change in body composition and biomarkers, at 20 and 52 weeks from baseline, between arms. DISCUSSION: Results of the trial may contribute to a better understanding of factors associated with recruitment, and acceptability, and will inform future exercise programs to optimally improve health outcomes for older BCS.

Sleep, quality of life, and depression in endometrial cancer survivors with obesity seeking weight loss.

PURPOSE: Incidence and mortality rates of uterine cancer are increasing and, obesity, which is also rising, has been associated with uterine cancer development and mortality. A recent study found that poor sleep quality is common among endometrial cancer survivors and those with obesity had more sleep disturbances than those having normal weight. However, it is unclear if higher levels of obesity (Class III, BMI ≥ 40 kg/m2), which are rising rapidly, are differentially associated with sleep as well as depression and quality of life in endometrial cancer survivors. METHODS: We evaluated sleep, depression, and quality of life in 100 Stage I endometrial cancer survivors with obesity seeking weight loss enrolled in a lifestyle intervention (NCT01870947) at baseline. RESULTS: The average age was 60 years and mean BMI was 42.1 kg/m2 with 58% having a BMI ≥ 40 kg/m2. Most survivors (72.3%) had poor sleep quality and most (71.2%) reported sleeping < 7 h/night. Survivors with class III compared with class I obesity had significantly more sleep disturbances and daytime dysfunction; and, those with poor sleep had higher depression and lower quality of life. Survivors with a BMI ≥ 50 kg/m2 (~ 25%) had the highest levels of depression and lowest physical and emotional well-being. CONCLUSIONS: Our results reveal that endometrial cancer survivors with class III compared with class I obesity have poorer sleep quality, higher depression, and lower quality of life. Given the rising rates of obesity and uterine cancer mortality, interventions to combat both obesity and poor sleep are needed.

Customer discovery as a tool for moving behavioral interventions into the marketplace: insights from the NCI SPRINT program.

The National Cancer Institute established a dissemination and implementation accelerator program called Speeding Research-tested INTerventions (SPRINT) in order to expedite the translation of behavioral research into practice. The goal of SPRINT is to introduce researchers to a new method for moving their research into practice in order to increase the real-world impact of their evidence-based interventions. The goal of this article is to present case studies on three teams that have completed the SPRINT program to date. Each case study provides a description of the intervention the team came into the program with, the team's motivation for participating in the SPRINT program, the team's experience in the program, lessons learned from "customer discovery" interviews conducted by the team during the course, and the team's future plans for their intervention. The case studies suggest that by focusing on behavioral researchers, SPRINT addresses an unmet need in the commercialization training space; that the definition of "success" can vary across SPRINT projects; that identifying and engaging "payors" for behavioral interventions is an ongoing challenge; and that there are potential "misalignments" between the research process and market demands. Overall, these examples show that customer discovery is a potentially useful method for making interventions more responsive to the needs of stakeholders, and that researchers can benefit from learning the "language" of business and working with individuals who have business experience before trying to move their research from the lab to the real world.

A National Study of Oncology Nurses Discussing Cancer Clinical Trials With Patients.

In the United States less than 10% of cancer patients engage in clinical trials. Although most oncology nurses have multiple opportunities to discuss clinical trials with patients, barriers including attitudes and social norms may impede these discussions. Guided by the Theory of Planned Behavior, we developed and evaluated measures for attitudes, subjective norms, and perceived behavioral control of nurses for discussing clinical trials with cancer patients. Of the 18,000 Oncology Nurse Society members invited, 1,964 completed the survey. Structural equation modeling and internal consistency reliability were used to evaluate items and constructs. We found that overall model fit and reliability was good: Confirmatory Fit Index (CFI) = 0.91, Root Mean Square Error of Approximation (RMSEA) = 0.05; attitudes, 21 items, alpha = 0.84; perceived behavioral control, 10 items, alpha = 0.85; and subjective norms, 9 items, alpha = 0.89. These measures of attitudes, subjective norms, and perceived behavioral control show good reliability and initial evidence of validity.

Importance of incorporating measures of attitude in planning and evaluating nursing education.

Learners' attitudes towards a topic or behavior has long been recognized as an important component in the evaluation of formal education as well as in achieving desired behavior change. However, attitudes are frequently neglected and evaluation of outcomes from continuing nursing education often includes only changes in knowledge and learner satisfaction. We describe measurement of attitudes of oncology nurses towards holding discussions with patients about the option of participating in a clinical trial, in comparison to what can be learned from measuring knowledge alone. This article illustrates important insights that can be gained through inclusion of measures of attitude in both designing and evaluating continuing education using data from a larger on-going study.

Perspective of older African-American and Non-Hispanic white breast cancer survivors from diverse socioeconomic backgrounds toward physical activity: A qualitative study.

BACKGROUND: We sought to explore the perspective of older breast cancer survivors (BCS) from diverse racial and socioeconomic backgrounds toward physical activity (PA) to inform the design of a PA program that fosters acceptability. METHODS: Participants included sixty women, ≥65years, within two years of treatment completion for stage I-III breast cancer. We purposely sampled ≥ten patients in each race [African-American (AA) and Non-Hispanic White (NHW)] and socioeconomic status (SES) [SES disadvantaged and SES non-disadvantaged] group. Participants completed in-person interviews (n=60) and follow-up focus groups (n=45). Thematic analyses were employed. RESULTS: The median age was 71.0years (range: 65-87years). Five themes emerged: 1) importance of PA; 2) current PA participants engaged in; 3) influence of race and culture on PA attitudes and beliefs; 4) barriers to PA and facilitators to PA; and 5) PA preferences. Barriers included health issues (43%), particularly cancer treatment side effects such as fatigue. Facilitators included religious faith (38%) and family (50%). Preferences included group exercise (97%) and strength training (80%) due to concerns participants had with diminished upper body strength after cancer treatment. Although AA (59%) and SES non-disadvantaged (78%) participants reported that race and culture influenced their attitudes toward PA, it did not translate to racial and SES differences in preferences. CONCLUSION: Among older BCS, physical activity preferences were shaped by cancer experience, rather than by race and SES. Physical activity programs for older BCS should focus on addressing cancer treatment-related concerns and should include strength training to ensure PA programs are more acceptable to older BCS.

Acute aerobic exercise increases implicit approach motivation for dessert images.

We examined the effect of acute exercise compared to a cognitive task on implicit approach/avoidance motivation to dessert food images using the Dessert-Approach-Avoidance Task. Participants randomized to exercise had a greater increase in approach motivation to dessert images compared to those completing cognitive tasks ( p=0.046), adjusting for disordered eating, task difficulty, and changes in negative affect. This study provides the first evidence for the use of the Dessert-Approach-Avoidance Task to evaluate the effects of acute exercise on implicit motivations for dessert images. Future studies should examine implicit response to food images using the Dessert-Approach-Avoidance Task in response to chronic exercise.

Neurobiology of substance use in adolescents and potential therapeutic effects of exercise for prevention and treatment of substance use disorders.

Substance use (e.g., alcohol, marijuana, opioids, cocaine., etc,) use often initiates during adolescence, a critical period of physiological and social development marked by an increase in risk-taking due, in part, to heightened motivation to obtain arousal from rewards. Substance use during adolescence has been associated with a greater risk of substance use disorders (SUD) in adulthood. Although use rates for most substances have remained relatively stable, the frequency of marijuana use and the perception that regular marijuana use is not harmful has increased in adolescents. Furthermore, the nonmedical use of opioids has increased, particularly in the South, Midwest, and rural low-income communities. Substance use in adolescence has been associated with adverse structural and functional brain changes and, may exacerbate the natural "imbalance" between frontal/regulatory and cortical-subcortical circuits, leading to further heightened impulsive and reward-driven behaviors. Exercise increases growth and brain-derived neurotrophic factors that stimulate endogenous dopaminergic systems that, in turn, enhance general plasticity, learning, and memory. Exercise may help to reinforce the "naïve" or underdeveloped connections between neurological reward and regulatory processes in adolescence from the "bottom up" and "offset" reward seeking from substances, while concomitantly improving cardiovascular health, as well as academic and social achievement. In this review, we provide an overview of the current state of substance use in adolescents and rationale for the utilization of exercise, particularly "assisted" exercise, which we have shown increases neural activity in cortical-subcortical regions and may modulate brain dopamine levels during adolescence, a unique window of heightened reward sensitivity and neural plasticity, for the prevention and adjunctive treatment of SUD.

Structural Equation Modeling.

Structural equation modeling (SEM) is a multivariate statistical framework that is used to model complex relationships between directly observed and indirectly observed (latent) variables. SEM is a general framework that involves simultaneously solving systems of linear equations and encompasses other techniques such as regression, factor analysis, path analysis, and latent growth curve modeling. Recently, SEM has gained popularity in the analysis of complex genetic traits because it can be used to better analyze the relationships between correlated variables (traits), to model genes as latent variables as a function of multiple observed genetic variants, and to assess the association between multiple genetic variants and multiple correlated phenotypes of interest. Though the general SEM framework only allows for the analysis of independent observations, recent work has extended SEM for the analysis of data on general pedigrees. Here, we review the theory of SEM for both unrelated and family data, describe the available software for SEM, and provide examples of SEM analysis.