The prevalence and seriousness of pediatric obesity has prompted calls for solutions that reach beyond clinic settings (Ogden, Carroll, & Flegal, 2008). Adverse outcomes associated with obesity are not limited to only physical health concerns, such as diabetes (Lee, 2008), but also to psychosocial well-being (Stern et al., 2007). Obese adolescents are more likely to experience teasing (Falkner et al., 2001), social isolation, (Strauss & Pollack, 2003) and lower self-esteem (Biro, Striegel-Moore, Franko, Padgett, & Bean, 2006). Among obese adolescents, low self-esteem has been associated with higher rates of sadness and loneliness and higher likelihood of engaging in risky behaviors such as using tobacco or alcohol (Strauss, 2000). Despite these psychosocial difficulties, most adolescent weight management interventions are primarily focused on physical health, with little or no attention to psychological or psychosocial well-being (Barlow, 2007). Yet, psychosocial well-being may play an important role in increasing participant motivation and success in weight management interventions. For these reasons, understanding factors that may impact psychosocial well-being and adolescents’ decision making about healthy lifestyle changes are essential for improving the efficacy of weight management programs. Thus, the objective of this study was three-fold: (1) describe the psychosocial well-being of obese adolescents in a multidisciplinary weight management program; (2) describe the barriers these adolescents face when making healthy changes; and (3) examine whether factors related to psychosocial well-being and the barriers they face are associated with level of compliance in the program.

Methods

Design and Participants

Study participants were enrolled in the T.E.E.N.S. (Teaching, Encouragement, Exercise, Nutrition, Support) weight management program, a two-year multidisciplinary program consisting of medical personnel, psychologists, exercise physiologists, and dietitians. T.E.E.N.S. comprises three phases: baseline (first 6 months), maintenance (months 7–12), and follow-up (months 12–24) and involves three components: nutrition, exercise, and behavioral support and modification. Participants were eligible for T.E.E.N.S. if aged 11–18, were ≥95th BMI percentile for their age and gender, had at least one adult in the household committed to the program, and had a primary care physician who was responsible for the participant’s other medical needs. Participants were referred from their pediatricians, school nurses, or self-referred. Written informed consent was obtained from all parents and assent from children participating in the study. Upon enrollment, participants completed three separate intake interviews, which focused on each component of the program (nutrition, exercise, and behavioral support). The study was approved by the Virginia Commonwealth University Institutional Review Board.

A total of 135 participants completed the initial assessment (67% African American, 62% female, M age = 13.71 years). Mean baseline BMI percentile for both genders was in the obese range (M BMI percentile = 98.96, SD = 0.98), with no significant gender or ethnic differences. Of the parents who reported their highest level of education (n = 76) and income level, (n = 75), 51% had a college degree or higher and 44% had an income of $50,000 or greater. Participants also completed the Child Depression Inventory (CDI; Kovacs, 1985) to assess depression (n = 77; M = 9.52, SD = 6.88, range = 0–36). This measure was added to the protocol after the study began, thus not all participants completed it. According to Kovacs (1992), a score of 19 and above identifies depression in non-clinical samples. Six participants scored in this range in this sample. Participants who reported suicidal ideation or depressive symptoms on the CDI and were deemed appropriate by the behavioral support specialist were referred for further mental health treatment. Table 1 summarizes participant characteristics.

Table 1 Demographics of participants
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Procedures

Information for this study was derived from the initial intake interview for the behavioral support component. These 30–60 min semi-structured interviews were conducted during the baseline phase by psychology doctoral students trained in conducting the interviews and supervised by a licensed psychologist. The following self-reported information was assessed: background history, family history, medical history, education, mental health history, history of trauma, physical activity and dietary habits, body image perception, and program goals.

For our study, we specifically explored responses to questions about teasing experienced, trauma experienced, past suicidal ideation, previous psychological treatment, medical problems (i.e., asthma, allergies), age of onset of weight gain, event(s) co-occurring with onset of weight gain, barriers to physical activity, and barriers to nutrition. Parents completed information about their marital status, highest education level and income level and provided information about their adolescents’ age at weight gain and the event(s) surrounding onset of weight gain. We examined the associations among factors related to psychosocial well-being and participants’ attendance compliance for the nutrition, exercise, and behavioral support and modification components of the T.E.E.N.S. program.

Analyses

First, we coded the responses to questions about teasing, trauma, past suicidal ideation, previous psychological treatment, and medical problems as dichotomous variables (either “yes” or “no”). We examined the responses to questions about the event(s) co-occurring with weight gain and barriers to exercise and nutrition to determine which themes were most frequently cited. We measured participants’ attendance compliance by the number of visits they completed for each component (exercise, nutrition, and behavioral support and modification). Second, we calculated frequency of occurrence for each of the factors related to psychosocial well-being (teasing, trauma, past suicidal ideation, previous psychological treatment, and medical problems), age at weight gain, event co-occurring with weight gain, and the barriers to exercise and nutrition. For 16 of the participants, information regarding barriers was absent; these participants were included in the total number for the frequency calculations. Third, we conducted multivariate analyses of variance (MANOVAs) to examine the associations among the factors related to psychosocial well-being and participants’ attendance compliance to the program as measured by the number of visits completed for each program component. Chi-square analyses yielded no ethnic and gender differences among factors associated with psychosocial well-being.

Results

Factors Related to Psychosocial Well-being

Fifty-six percent of participants reported experiencing weight-based teasing and 30% reported experiencing a type of trauma. Traumatic events noted included: motor vehicle accidents, abusive family relationships, neighborhood violence, and death of a loved one. Thirty-eight percent reported receiving previous mental health treatment and 22% reported experiencing past suicidal ideation. Sixty-nine percent reported having medical issues including: allergies, asthma, borderline Type 2 diabetes and hypertension, back pain, and Attention Deficit Hyperactive Disorder (ADHD).

Factors Co-Occurring with Onset of Weight Gain

About one-third (30%) of participants and their parents reported that the onset of the child’s weight gain occurred between ages 9–11. Participants reported various events that precipitated this weight gain. Many (33%) stated that no event triggered the weight gain, while 19% indicated that changes in the family situation, such as divorce or illness, were significant triggers. Other events/triggers included: medical issues (13%), unhealthy diet (13%), lack of exercise (9%), relocation (8%), and interpersonal issues with peers (3%).

Barriers to Exercise

Sixteen percent of participants did not report experiencing a barrier to exercise. For the remaining participants, we were able to identify seven frequently cited themes. The most commonly cited barrier was medical conditions (16% of participants), with weight, asthma, back pain, and ankle pain reported as problem areas. Lack of motivation and energy to participate in exercise (16%) and parents’ work schedules were also barriers reported (15%). With respect to the latter, several participants reported transportation issues as a result. Other barriers reported were lack of safety and lack of peers in neighborhood, dislike for exercise, negative peer influence, and preference for sedentary activities such as watching television, playing video games and using the computer. See Table 2 for frequencies.

Table 2 Barriers to exercise and nutrition (N = 119; missing = 16)a
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Barriers to Nutrition

Notably, 31% of participant did not report experiencing a barrier to healthy eating. However, among those who did, seven frequently cited themes were identified. The most commonly cited perceived barrier was family eating habits (18%), which included eating out, unhealthy cooking styles, and unavailability of healthy food in the home. Participants also indicated that their own eating habits (12%), such as eating large portion sizes, eating too quickly, eating when bored, and snacking were barriers. Other barriers reported included: busy schedules not allowing time for meal preparation, financial limitations, peer influences, temptation for unhealthy food and disliking taste of healthy food. See Table 2 for frequencies.

Attendance Compliance to Program

Trauma was the only psychosocial factor (out of teasing, trauma, suicidal ideation, previous psychological treatment, and health problems) that was significantly associated with participants’ attendance compliance. Participants who reported experiencing a trauma had significantly lower compliance than participants who did not, F (6, 76) = 2.41, p = .036. Differences were found in all three components of the program: total number of behavioral support visits, F (1, 24) = 11.21, p = .001, total number of nutrition visits, F (1, 24) = 11.32, p = .001, and total number of gym visits, F (1, 24) = 5.16, p = .026.

Discussion

The purpose of this study was to describe the psychosocial well-being of ethnically diverse, obese adolescents in a multidisciplinary weight management program, describe the barriers to making healthy changes, and examine whether factors related to psychosocial well-being and the barriers these adolescents face are associated with level of compliance in the program. We found that over half of the participants reported experiencing weight-based teasing and medical issues. Although diagnostic interviews were not conducted and mental health diagnoses are not known, mental health issues were also prevalent with many participants indicating that they have experienced past suicidal ideation, a traumatic event and have participated in previous mental health treatment. In particular, adolescents who had a past experience of trauma were less likely to comply with the program by participating actively in nutrition, exercise, and behavioral support and modification sessions. Trauma has been associated with binge eating disorder and night eating syndrome, two eating disorders that have been associated with obesity (Allison, Grilo, Masheb, & Stunkard, 2007). Although outcome data were not available for this study, it is possible that trauma may have also influenced weight loss and other outcomes via poor compliance. These findings strongly suggest a need for addressing both physical and mental health concerns in this population.

We also found that familial factors have an important role in weight gain and barriers to exercise and nutrition. Among participants who reported a precipitating event to onset of weight gain, family events, such as divorce, were the most commonly reported. Parental factors, such as work schedules and the family’s eating habits, were among the most frequently cited barriers to healthy eating and exercise. Thus these results, consistent with previous research (Wald et al., 2005), demonstrate the importance of the family environment and family support in designing pediatric obesity interventions. Also consistent with the literature, peers were influential agents for the adolescents’ exercise and eating behaviors (McCabe & Ricciardelli, 2005). Individual factors, such as perceived lack of motivation, are another barrier that warrants further exploration. A large number of participants did not report experiencing barriers to exercise (16%) and nutrition (31%). This may suggest that at the onset of the T.E.E.N.S. program, many youth lack an awareness of barriers to healthy living. It is possible that once participants begin to make lifestyle changes, a greater awareness of barriers would emerge. Further research is needed to clarify and fully understand the factors underlying motivation for behavioral change for this population.

Because of the cross-sectional nature of the study, we cannot infer direction or causation for obesity and these psychosocial factors and barriers. Another limitation to this study is the sample selection. The method of recruitment (referrals by pediatricians and school nurses) and eligibility requirements (only with parents willing to participate) may have created selection bias to the results and impacted generalizability. Further, this sample included obese adolescents already in a weight management program and thus these results may not be generalized to the general population of obese adolescents or non-obese adolescents. A follow-up study with a more open referral process, incorporating a larger and more diverse sample, and a comparison group of non-obese adolescents or obese adolescents in a community setting would increase the interpretability of the results. Including a diagnostic interview or other means of assessing mental health diagnosis before and after participating in weight management programs may be beneficial, due to the frequency of mental health issues reported. In addition, this study did not explore the potential ethnic differences in other cultural and social factors such as dietary habits, food choices, and body image, thus adding more breadth to the study. Lastly, all of the measures used were self-report and the responses may have been affected by the fact that participants were already enrolled in a weight management program. Despite these limitations, the results of this study demonstrate the importance of exploring and addressing psychosocial well-being in obese adolescents. Further, findings about the importance of family and peers as barriers to healthy behaviors and as factors precipitating weight gain provide support for a systems approach to weight management. A systems approach which addresses the deleterious impact of psychosocial stressors on adolescent health likely would help adolescents achieve the greatest benefits.