Motivational interviewing and cognitive behaviour therapy in the treatment of adolescent overweight and obesity: Study design and methodology☆
Introduction
It is currently estimated that approximately 25% of Australian young people are overweight or obese [1], [2]. Rates have increased dramatically in recent years and there is nothing to suggest that the rate of increase is slowing [1]. Thus the prevalence of overweight and obesity is likely to continue to increase. Obesity tracks into adulthood such that an obese 13-year-old has a 50% chance of being an obese adult and an obese 18-year-old has nearly an 80% chance of being obese in adulthood [3]. The presence of obesity during childhood and adolescence increases the risk of numerous physical complications independently of adult obesity. Additionally, the longer the individual is overweight or obese, the more serious these physical complications become [3], [4], [5], [6]. Consequently, the high prevalence of overweight and obesity in young people is particularly concerning.
Excess body weight is associated with increased mortality and morbidity rates. Numerous chronic and debilitating illnesses, including type II diabetes, coronary heart disease, some cancers and musculoskeletal disorders, and disorders that reduce quality of life such as arthritis, respiratory difficulties, skin problems, sleep apnea and infertility, are more common in overweight and obese individuals [7]. Many of these disorders, once thought to occur only in adults, are now being diagnosed in overweight and obese adolescents. Overweight and obesity also increase the risk of a variety of psychosocial problems including body image disturbance, low self-esteem, disordered eating and depression [8], [9], [10].
The strong tracking of adolescent obesity into adulthood, and the immediate and long-term negative biopsychosocial consequences of adolescent obesity, highlight the need for effective intervention in this population. Despite this identified need for treatment very few studies have explored the effectiveness of weight loss interventions for adolescents [11]. The relative neglect of adolescent obesity may be due to the complexities associated with studying this population. The study of adolescent body composition is made more complicated by the physical changes associated with puberty. Additionally, researchers may be hesitant to offer interventions to adolescents because of the difficulties associated with working clinically with this population. The lack of research in this area means clinicians working with adolescents have a limited empirical literature upon which to base their practice [11], [12]. As a result “adolescents are in danger of falling in the ‘gap’ between paediatric services and adult services” [13, p. 50].
Only a small number of studies have systematically examined the effectiveness of overweight and obesity intervention in young people. The majority of these studies were too small to have sufficient power to detect an effect and they used various physiological measures making comparisons across studies difficult [11], [12]. Consequently, several systematic reviews of the child and adolescent overweight and obesity treatment literature have concluded that it is not possible to conduct a meta-analysis using the existing studies [11], [12]. The reviewers recommended that the standard of future intervention trials could be improved by conducting a priori calculation of sample size, using better randomisation methods, and reporting intention-to-treat analyses. It is also suggested that medical, behavioural and psychosocial outcomes and the psychosocial influences on behaviour change and predictors of outcome be explored. The inclusion of maintenance strategies and long-term follow up, and improvement of clinician attitudes and therapeutic techniques have also been identified as important for future research [11], [12].
Given the lack of research exploring the treatment of adolescent overweight and obesity, the results of child and adult overweight and obesity interventions must be used as the basis for adolescent interventions. A number of studies of childhood interventions incorporating improved dietary habits, increased physical activity, reduced sedentary behaviour and parent training in behaviour management have demonstrated maintained weight loss up to 10 years after treatment [14], [15]. Consequently, the use of a developmentally appropriate approach incorporating behavioural modification and family support to promote dietary change, increased physical activity, and decreased sedentary behaviour is recommended for the treatment of child and adolescent overweight and obesity [16]. While data on their long-term effectiveness is lacking, more intrusive treatment approaches such as very low calorie diets, pharmacotherapy and surgery are being increasingly used with adolescents. The Australian National Health and Medical Research Council recommends that more conventional treatment strategies, namely eating and physical activity changes, family support and behaviour modification should be implemented prior to attempting more intrusive treatment techniques. They further advise that if medical treatments are implemented they should be preceded and accompanied by these lifestyle interventions [17].
Adult weight loss interventions have demonstrated some short-term success, however the majority of adult weight loss interventions have failed to demonstrate maintained improvements with most participants regaining all the weight they lost within 5 years [18], [19]. The Australian National Health and Medical Research Council advocates a stepped model approach for the clinical management of overweight and obesity in adults. The model promotes education and lifestyle skills training as the initial approach for the treatment of adult overweight and obesity. More comprehensive cognitive behavioural interventions are recommended for those with patterns of cognitions, behaviours or emotions likely to impact on weight loss. While medical interventions such as very low calorie diets, pharmacotherapy and surgery are recommended for heavier individuals with existing co-morbidities, lifestyle changes resulting from cognitive behavioural intervention are considered fundamental additions to these more intrusive treatment approaches [20].
The majority of contemporary weight loss interventions focus on dietary change with the promotion of low-fat, low-carbohydrate or high-protein diets. Some more recent interventions also incorporate increased exercise or physical activity. To date, the majority of intervention approaches have been unable to produce the long-term behaviour changes that are required for sustained weight loss [19]. Stuart [21] revolutionised the weight loss field by incorporating behaviour therapy strategies, such as relaxation and stimulus control, into standard weight loss interventions. The incorporation of these strategies led to increased weight loss and improved maintenance in weight loss interventions. Behavioural strategies are now incorporated into most modern day weight loss interventions. However, since Stuart's [21] contribution, there has been very little extension of the role of psychology in the weight loss field.
In response to the increased demonstration of the effectiveness of cognitive behaviour therapy in the field of psychology, weight loss interventions have begun to incorporate cognitive behaviour therapy strategies. Cognitive behaviour therapy has been used extensively with adolescents and has demonstrated success in initiating and sustaining behavioural changes in a range of other disorders in [22]. However, the role of cognitions in obesity development and treatment and the potential use of cognitive behaviour therapy in obesity intervention have not yet been fully explored [23].
Motivational interviewing, a technique developed in the treatment of alcoholism and now used widely in the drug and alcohol field, aims to assist the individual to become ready for change [24], [25]. This treatment approach has demonstrated success in initiating and sustaining behavioural changes in a range of other disorders [26], [27]. Motivational interviewing has been used in conjunction with cognitive behaviour therapy to increase treatment initiation and completion rates and to improve treatment outcomes [e.g., 28]. However, the use of motivational interviewing in the treatment of overweight and obesity has received very little attention in the theoretical and empirical literature [27].
While there is a need for effective treatment of overweight and obesity in all age groups, the adolescent population is particularly in need of effective evidence based interventions. The tracking of obesity from adolescence to adulthood, combined with the treatment resistant nature of adult obesity, suggest that targeting this population may be an effective and efficient way to prevent adult obesity. Concomitantly, the high prevalence of adolescent overweight and obesity, and the increased biopsychosocial impact of being overweight at a younger age, and being overweight for a longer period of time, highlights the importance of targeting this at risk population immediately. Therefore, the primary aim of the present research is to examine the efficacy of cognitive behaviour therapy and motivational interviewing in the treatment of adolescent overweight and obesity. A secondary aim of this research program is to redress the limited information available on the behavioural and psychosocial factors associated with adolescent overweight and obesity.
Section snippets
Study design
This study was a randomised controlled trial in which 63 adolescents and their parents participated in either a motivational interview or a standard semi-structured assessment interview. Following completion of all pre-treatment assessments participants were randomly allocated to a treatment or wait-list control condition. Individuals in the treatment condition received 13 sessions of cognitive behavioural intervention over 4 to 6 months, those in the wait-list control did not receive any
Recruitment
Recruitment commenced in January 2003 with further major recruitment drives conducted in July 2003 and January 2004. Participants were assessed and randomised as soon as possible after recruitment. Those allocated to the treatment condition commenced treatment immediately after randomisation. The first participant commenced treatment in July 2003, and the final participant completed intervention in December 2005. A total of 120 parents completed intake questionnaires and were provided with
Discussion
Despite the dramatic rise in the prevalence of adolescent overweight and obesity, and an increasing awareness of the negative physical and psychosocial consequences of this epidemic, few studies have explored the effectiveness of weight loss interventions for this age group [11], [12]. Consequently clinicians working with adolescents have a limited empirical literature upon which to base their practice, and few treatment options are available for adolescents. While Australian guidelines
Conclusion
In conclusion, we have described the rationale and design for a randomised controlled trial designed to assess the efficacy of a cognitive behavioural intervention for the treatment of adolescent overweight, and the impact of a preceding motivational interview on the efficacy of this intervention. Baseline data has also been described. Findings from the present study will provide a comprehensive assessment of the biopsychosocial factors associated with adolescent overweight and obesity and its
Acknowledgements
The first author was funded by a RMIT University Postgraduate Award and a VicHealth Postgraduate Scholarship. Supplementary funding was provided by the ATN Centre for Metabolic Fitness and the Parenting Research Centre.
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The first author was funded by a RMIT University Postgraduate Award and a VicHealth Postgraduate Scholarship. Supplementary funding was provided by the ATN Centre for Metabolic Fitness and the Parenting Research Centre.