Promoting Behavioral Change in Overweight Youth

With obesity on the rise nationally, the frequency of overweight children presenting in a variety of medical settings is growing. Treatment of obesity is critical given its association with a variety of medical disorders as well as psychiatric conditions, lowered quality of life, and social dysfunction. Health care providers in a variety of settings are increasingly called upon to treat this condition, often with little or no information on how to energize patients toward changing long-standing maladaptive eating and activity patterns. Health care providers may be at a loss for specific recommendations and educational information to give to parents. In this article, we offer a list of online resources and books, as well as parent education handouts, to address the main issues involved in behavioral change for these overweight youth, with specific and practical recommendations regarding increasing physical activity, maximizing nutritive value of food intake, and encouraging self-change. We also emphasize family lifestyle changes given the importance of family changes on changes in youth.

For over 40 years, national surveys have shown an increase in frequency of overweight children and adolescents (Manson, Skerrett, Greenland, & YanItallie, 2004). We know that overweight youth have an increased risk for medical disorders such as Type II diabetes, cardiovascular disease, and increased morbidity and mortality (Must, Spadano, Coakley, Field, Colditz, & Dietz, 1999). These children are also at risk for a variety of psychological disorders and conditions such as depression, low self-esteem, anxiety disorders, hopelessness, suicidal ideation, social isolation, peer teasing, somatoform disorders, and chronic pain (Buddeberg-Fischer et al 1999, Eisenberg et al 2003, Falkner 2001, French et al 1995, Pesa et al 2000, Strauss and Pollack 2003). Moreover, their quality of life is significantly impaired, as shown by a recent study demonstrating that obese children rated their quality of life similarly to that of pediatric cancer patients and significantly worse than that for a normative population of children (Schwimmer, Burwinkle, & Varni, 2003).

Given the seriousness of the comorbid conditions, and the increasing frequency of overweight youth in our society, health care professionals in a variety of settings must find ways to treat these individuals. While many clinicians know that increasing physical activity and diminishing overall caloric intake, and especially saturated fat intake, are key components of treatment, they often do not know specific recommendations to achieve these goals. They also may not know how to help their patients surmount a variety of barriers that prevent personal change such as limited financial resources, family member involvement, mood state, personality style, behavioral resistance, etc. This condition, therefore, has been difficult to successfully treat in pediatric medical settings.

To aid in this treatment process, we have devised a variety of handouts and a list of resources for parents to aid them in following medical, nutritional, and physical activity recommendations. These handouts provide educational information regarding common problems in nutritional intake, eating behaviors, physical activity, etc. Given that some studies show that educational interventions alone have not been successful for weight loss in youth (Epstein et al 1985, Stolley and Fitzgibbon 1997), there are also handouts that incorporate behavioral change techniques applied to these nutrition and activity behaviors. It should also be noted that there is an emphasis on family change and family goals in these handouts, consistent with the belief that 1) youth copy their parents’ behaviors; 2) parents have control over some aspects of the change process such as what food is in the home, where/how often they eat out, and transportation to certain physical activities; and 3) parents are in a position to reward youth for making positive choices and reaching behavioral change goals.

These handouts are not designed to replace appropriate health care and follow-up, but rather to be used by the practitioner as 1) preventative information for children and their families when the youth’s weight is in the at-risk-for-overweight category; 2) preventative information for youth and their families when the youth is exhibiting maladaptive nutrition or activity behaviors regardless of current weight status; or 3) as an educational supplement to medical care in either a general or specialty care setting. Use of these handouts does not preclude appropriate referrals for assessment, treatment, or both for being overweight such as multidisciplinary specialty clinics. The practitioner should consider consultation with a specialty clinic in morbidly overweight youth with comorbid conditions or those failing to respond to treatment. Use of the handouts also does not preclude appropriate referrals for specialty care for any of the comorbid conditions associated with being overweight. Common co-morbid conditions that may be handled by the practitioner with appropriate consultation include hyperlipidemia, asthma, hypertension, type II diabetes, hyperinsulinemia, and depression.

Behavioral change can be particularly difficult in individuals with mood disorders, stressful or unsupportive family situations, behavioral difficulties, or certain personality styles. If these issues are suspected of impeding progress, the clinician is encouraged to seek a referral for psychological evaluation and treatment. Addressing maladaptive family patterns and dynamics, retraining of maladaptive cognitions, emotion and stress management, problem-solving strategies, improving motivation to change, and instigating self-management of behavior are all psychological techniques that could be helpful in surmounting these barriers and enhancing progress toward behavioral change and treatment goals.

In fact, there is empirical support for combining psychological interventions with more standard medical and nutritional interventions. For instance, studies suggest that in patients with Type I diabetes mellitus, coping skills training is useful in preventing weight gain and improving metabolic control and psychosocial well-being (Grey et al 2000, Grey et al 1998, Gross et al 1982, Gross et al 1983, Kaplan et al 1985). Further, Grey and Berry (2004) demonstrated that a school-based Type II diabetes prevention intervention for multi-ethnic youth combining nutritional education, exercise and coping skills training resulted in helping these youth increase activity, improve nutrition status, and stabilize glucose and insulin metabolism. The patient handout, courtesy of Arkansas Children’s Hospital, offers specific strategies to help individuals make important lifestyle changes.

Co-morbid conditions that require a referral for immediate attention include pseudotumor cerebri, slipped capital femoral epiphysis, Blount’s disease, non-alcoholic hepatosteatosis, sleep apnea, hypoventilation syndrome, and cholelithiasis. Regardless of co-morbid conditions, educational information regarding nutrition, exercise, and behavior change will be an important part of the intervention

For further information on additional educational information regarding overweight youth, please contact the authors. We also offer a list of resources for parents in Box 1.

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