Program background

The development of effective treatment programs for pediatric obesity remains a national priority (Institute of Medicine, 2004). The incidence of obesity in adolescence, in particular, has more than tripled in the past 30 years (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Currently, treatments in the field yield mixed results in the long-term treatment of this disease among this age group, and researchers highlight the need for continued effort in intervention development (Kitzmann & Beech, 2011; Safron, Cislak, Gaspar, & Luszczynska, 2011). There are numerous considerations to make when developing an adolescent treatment program, including: who should be involved, in what format, and how best to ensure accessibility, treatment adherence and continuity of care. 

Program design

The Center for Youth Wellness (CYW) at Floating Hospital for Children at Tufts Medical Center was founded in 2008 to provide treatment for overweight/obese adolescents. Our teen weight management program has been designed from an ecological model of development (Bronfenbrenner, 1979). We recognize the multilayered complexity of a teenager’s life, including family, peer, school, community and societal factors. With this model, we seek to provide treatment that is contextual and relevant to these interconnected spheres. Several key components of our program stand out in this regard.

First, we specifically designed our 10-week program utilizing a peer group format unique to the adolescent population. In the treatment of childhood obesity, the evidence strongly supports the role of parent training as an integral part of treatment programming (Luttikhuis et al., 2009). Research on adolescent treatment programs, however, remains mixed regarding the degree to which parent involvement improves outcomes (DeBar et al., 2012; see also Kitzmann & Beech, 2011 for review). Generally speaking, adolescents are at a developmental stage when they are seeking increased independence from caregivers, autonomy in decision-making and peer support (Fuligni, 1998). Thus, programs striving to be developmentally sound do right to address these emerging skills. At the same time, these considerations must be weighed within a cultural context, keeping in mind that independence and autonomy seeking are values that lie on a culturally dependent continuum (Fuligni, 1998). Our team has sought to strike a balance between providing opportunities for increased individual decision-making and peer support as well as encouraging teens to build on current support systems in their lives, including family members and mentors.

Our development of a peer model stems from empirical and clinical data that suggest obese teens may be particularly in need of increased social support in order to effect change. Indeed, extant literature shows that obese youth are at increased risk for a range of psychosocial problems, including lower quality of life and social isolation (Schwimmer, Burwinkle, & Varni, 2003; Strauss & Pollack, 2003). Our clinical experience echoes these studies as many of our patients mention feeling alienated from peers. Even those who describe strong friendships state that there are certain areas (e.g., eating and clothing), which they feel their friends “just don’t understand.” One of our goals is to provide a safe place for teens to connect with other teens struggling with similar problems to support and learn from one another. Moreover, research shows that peers can have a positive influence for teens in making and maintaining goals (DeBar et al., 2012). We also recognize the importance of education at the family-level. Although families are often eager to learn how best to support their children, research has shown that obese youth are at risk for being teased by family members about their weight (Eisenberg, Neumark-Sztainer, & Story, 2003). We offer a session devoted to informing adult family members about the program’s main messages and how best to support their teens during and after participation. 

Another important design component addresses the issue of access and cultural relevance. Given that access to weight management treatment can be limited, the CYW team has made a commitment to provide an accessible, affordable and culturally sensitive program. Our programs are located in urban areas, serving mostly low-income, minority populations with high rates of pediatric obesity and need for low cost, specialized care (Smith, 2010). Sessions are held during afterschool hours and are accessible by public transportation. Our pre-enrollment and followup visits rely on insurance reimbursement, and families are responsible for associated copays if applicable. Through foundational support, participation in the group program is free to all families.

A final consideration for our program addresses its brevity and the need for continuity of care after participants complete it. To begin, we communicate openly with our participants’ primary care providers to ensure effective communication and transitions between care providers. Secondly, through our YMCA partnership, CYW is working from a sustainable care model that promotes the maintenance of healthful lifestyle habits in a setting that is community-based and conducive to the needs of adolescents — peer involvement, enjoyable activities, easy access and affordability. As part of the program, participants are given a free 12-week membership to the YMCA, and family passes are also made available. One of the great benefits of the program is the relationship participants make with fellow participants as well as Y staff.  We hope that our program is a starting point for teens and that, once comfortable and familiar with the YMCA setting, they will continue to remain an active member long after program completion. We specifically chose the YMCA centers because they offer a range of youth activities and educational programs with a mission to empower youth to maintain healthful lifestyles. Once “hooked in”, our participants have the opportunity to maintain their activity goals, develop friendships with other teens with similar goals, and participate in afterschool programming that keeps them active, social, and engaged with their immediate community.

Program components

Currently, our program operates as a Stage Three multidisciplinary weight management program for 11- to 18-year-olds, employing a physician, registered dietitian, psychologist and support staff. As noted, CYW has developed an approach to adolescent weight management, which seeks to address the developmental strengths and vulnerabilities of adolescence as well as potential barriers to treatment. Eligible teens have a BMI-for-age = 95th percentile or = 85th with co-morbidities, are interested in losing weight, and can commit to the 10-week afterschool program. It includes a two-part assessment visit, a 10-week structured group program for youth, education and support for parents, and open communication between clinicians and the adolescent’s primary care provider. The 10-week structured program has two main components: nutrition/wellness education and physical activity. We have developed a curriculum that is relevant to teens addressing such topics as food marketing and selecting healthful food choices in a variety of settings, such as the home environment, school lunch, fast food restaurants, convenience stores and vending machines. Wellness topics include goal setting and problem solving skills, emotion-based eating, sleep hygiene and stress reduction. The physical activity component introduces teens to a range of activities, including strength, cardiovascular and flexibility based exercises. Classes are organized to be fun and interactive with hands-onactivities to increase knowledge retention and skill development. Many of the physical activities build off of our psychoeducation component. In line with motivational principles, we recognize that the most effective change is self-initiated and a small step above what teens are already working on in their lives. We try to engage teens in developing individualized goals and plans that fit within their unique lifestyles. Restrictive diets are not prescribed. Rather, the focus is on youth to increase nutrition knowledge and problem solving skills so that they can make changes most important to them. By encouraging teens to make personal choices, we seek to address significant barriers to treatment compliance and long-term success. After program completion, participants are invited to attend a monthly weight maintenance group for continued educational and emotional support from peers and staff.

Ongoing challenges

Although our program has been well-received by teens and their families, we continue to face challenges with recruitment and treatment adherence. Although teens show interest in the curriculum, many personal and environmental barriers appear to make it difficult for them to implement acquired skills. We continue to explore how best to address adherence obstacles. In addition, although weekly attendance by teen participants remains high, parent attendance at our parent session is low in certain communities. Although afterschool programming works well for the teenagers, it can pose a significant obstacle for working parents. Balancing these different needs remains an ongoing challenge. Nevertheless, we remain enthused by participant response and look forward to continued refinement of our program. Its benefits are best summarized by one program graduate. She writes: “This program taught me that it is possible to eat and be healthy without starving myself. It gave me the tools to lead a healthy life and with patience and determination changes can be made. It was also very supportive. I made amazing friends and had great discussions. Through this program I learned how to lead a healthy lifestyle, and that I am not in it alone.”

Susan Meagher, PhD, is the psychologist for the Center for Youth Wellness at the Floating Hospital for Children at Tufts Medical Center. She is an assistant clinical professor at Tufts University School of Medicine and a practicing child clinical psychologist in Tufts’ Psychiatry Department. She is active in intervention research, previously in the area of preschool development and more recently in adolescent obesity. She has clinical interests in the connection between emotional and physical well-being, the role of developmental/family transitions in health behaviors, and the treatment of mood and anxiety disorders in children and teens.

Michael Leidig, RD, LDN, CPT, is a registered dietitian and certified personal trainer specializing in weight management. He has worked in the child/adolescent and adult weight management fields since 2000 and has expertise in the design, management, and evaluation of clinical programs and research studies. Currently, Michael is the clinical director of the Center for Youth Wellness at the Floating Hospital for Children at Tufts Medical Center, where he oversees weight management programming for youth and families within the Department of General Pediatrics as well as nutrition outreach and education to the surrounding community. Michael also maintains Nutrition & Fitness Advisors, a telephone-/internet-based nutrition and fitness consulting practice founded in 2002.

References

• Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, Mass.: Harvard University Press.

• Debar, L., Stevens, V., Perrin, N., Wu, P., Pearson, J, et al. (2012). A primary care-based, multicomponent lifestyle intervention for overweight adolescent females. Pediatrics, 129, e611-e620. doi: 10.1542/peds.2011-0863

• Eisenberg, M.E., Neumark-Sztainer, D., & Story, M. (2003). Associations of weight-based teasing and emotional well-being among adolescents. Archives of Pediatrics & Adolescent Medicine, 157(8), 733-738.

• Fuligni, A.J. (1998). Authority, autonomy, and parent–adolescent conflict and cohesion: A study of adolescents from Mexican, Chinese, Filipino, and European backgrounds. Developmental Psychology, 34, 782–792. doi: 10.1037/0012-1649.34.4.782

• Institute of Medicine. (2004). Preventing childhood obesity: Health in the balance. Washington, D.C.: National Academies Press.

• Kitzmann, K., & Beech, B.M. (2011). Family-based interventions for pediatric obesity: Methodological and conceptual challenges from family psychology. Couple and Family Psychology: Research and Practice, 1, S45-62. doi:10.1037/2160-4096.1.S.45

• Luttikhuis, H.O., Baur, L., Jansen, H., Shrewsbury, V.A., O’Mally, C., Stolk, R.P., et al. (2009). Interventions for treating obesity in children. Cochrane Database Systematic Reviews, 1, CD001872.

• Ogden, C.L., Carroll, M.D., Curtin, L.R., Lamb, M.M., & Flegal, K.M. (2010). Prevalence of high body mass index in U.S. children and adolescents. Journal of the American Medical Association, 303, 242–49.

• Safron, M., Cislak, A., Gaspar, T., & Luszczynska, A. (2011). Effects of school-based interventions targeting obesity-related behaviors and body weight change: A systematic umbrella review. Behavioral Medicine, 37, 15-25. doi: 10.1080/08964289.2010.543194

• Schwimmer, J.B., Burwinkle, T.M., & Varni, J.W. (2003). Health-related quality of life of severely obese children and adolescents. Journal of the American Medical Association, 289, 1813-1819. doi: 10.1001/jama.289.14.1813

• Smith, S. (2010, September 9). Alarms on youth obesity in Mass. The Boston Globe.

• Strauss, R.S., & Pollack, H.A. Social marginalization of overweight children. Archives of Pediatrics & Adolescent Medicine, 157, 746-752.