Assessing and Surmounting Barriers to Eating and Activity Changes in Overweight Youth

By Ward-Begnoche, Wendy Thompson, Julia

Family-Centered Care provides a forum for sharing information about basic components of caring for children and families, including respect, information sharing, collaboration, family-to- family support, and confidence building. It seems straightforward- so simple to understand. What we put in our bodies (energy in) minus how active we are (energy out) equals our current weight. So for those trying to lose weight, this means eat less, exercise more, and you will lose weight.

This is the basic message underlying the work of a variety of clinicians who deal with overweight youth (medical, nutrition, psychology, physical therapy, etc.). So why is this seemingly simple recommendation so hard for these youth and families to follow? Why are they showing no improvement in their weight? Or worse yet, why do they get discouraged and stop trying? It is puzzling, until you talk with these children about why they find it so difficult to lose the weight. Their answers are the key to finding successful strategies to overcome their weight loss barriers.

The first author has worked with overweight youth with comorbid medical disorders (in an outpatient psychiatric setting, an inpatient medical setting, and a multidisciplinary medical specialty clinic setting for overweight youth) for more than 10 years. The following section delineates the common barriers that she has encountered in her extensive clinical work and the solutions she has found for these barriers.

Identifying Barriers to Change and Possible Solutions

Information/Misinformation in Nutritional Concepts

When working with these children, one quickly discovers that their understanding of key nutritional concepts such as “portion size,”"balanced nutrition,”"healthy eating,” and “low fat” is misinformed. Unfortunately, using this terminology with patients does not get the message across.

Few patients, if any, have an accurate knowledge of “portion size” for different foods. Adults consistently overestimate portion sizes (Bryant & Dundes, 2005). Servings that patients see in restaurants, fast food establishments, on television, modeled by their peers, and provided at home are much larger than an actual recommended portion size.

Even after patients have been told to reduce their portion sizes, many children and adolescents mistakenly believe that they have made adequate changes; however, these changes are not enough to meet recommendations for their age or enough to significantly reduce their weight. Using pictorial representations of appropriate portion sizes can aid in improving patients’ estimations of portion sizes (e.g., life-size picture of golf ball or tennis ball) (Byrd- Bredbenner & Schwartz, 2004). For specific information on teaching parents of preschoolers about appropriate portion sizes, see Bish and Gottesman (2005).

A “balanced meal” often has a general meaning of adding more fruits and vegetables, but this definition does not include how much should be added from different food groups or how often to choose from them. Increasing fruits and vegetables is one common recommendation, but without other changes, this only increases overall calories and does not address the amount of saturated fat, which usually needs to be reduced, or needed nutrients like calcium, vitamin D, and iron, which are often deficient in overweight patients.

One technique to initiate a discussion about food selection and portion size is to have patients and their families attend an “all you can eat buffet” and choose a healthy meal. Have them take a picture of their plate and bring it in or have educational pictures available to use. Patients also can use free nutrition-analysis Web sites and enter their intake. They will receive detailed output not only regarding calories and fat grams but also about various vitamins and minerals (www. usda.gov has a Nutrition Analysis Tool for instance). They can bring in their printouts or use a terminal in the office to enter in the last 24 hr of intake to stimulate discussion.

Patients may also define “healthy eating” differently. Definitions may include appropriate portion sizes, sometimes adding more fruits and vegetables, and sometimes cutting back on fat and calories. However, it is often associated with the word “diet,” which, to the patient, means a temporary and drastic restriction in their food intake, flavorless/unsatisfying food, and a corresponding unpleasant physical state. Instead, healthy, tasty menu options (breakfast, lunch, dinner, and snacks) can be offered to patients via handouts or pictures.

Healthy eating should also include the idea of eating a variety of foods. Children and adolescents should be encouraged to try new foods, especially fruits and vegetables, and be encouraged to help out with both the shopping and the cooking. A handout with new foods to try each week (tried several times during the week to promote taste acceptance) is helpful. Having a new food available each time patients visit the clinic (a “tasting center”) with small portion sizes and rewards for trying something new, even if they do not like it the first time, is an excellent way to promote this healthy habit. Examples that are tasty might include strawberries and Cool Whip, pepper strips with salsa or marinara to dip in, apple slices with yogurt dip, etc.

Many youth find the term “low fat” confusing. Some interpret this as eating little or no fat at all. Some have heard the recent media attention to “trans fats” and have some idea they should eat less of those. Others know there is something like “good fat” and “bad fat” but do not have any idea how to distinguish the two. Here, education is critical in explaining the differences between total, unsaturated, saturated, and trans fat. Also, an explanation of how to read a nutrition label can give youth and their families the tools for evaluating the foods they eat. Concrete examples with food labels as well as a handout to take home are helpful. Discussing real-life choices, such as in vending machines, fast food restaurants, and convenience stores, is critical.

“Metabolism” is another frequently misunderstood concept. It is critical that patients understand why skipping meals (reducing calories) leads to lowered metabolism and decreased weight loss rather than increased weight loss.

None of the misunderstandings related to the phrases above are, of course, what is meant by practitioners who use them with their patients. However, it is common practice to use these terms and other similar ones in making recommendations without regard to the patients and families’ levels of understanding. Using these terms without defining them to patients often leads to misunderstanding and miscommurtication, which stagnates progress.

Developing your own educational handouts or using those already created (Ward-Begnoche & Gance-Cleveland, 2005) can provide an overview that is helpful in clarifying nutritional terms and goals. It is often up to the clinician to fill in the parent and child’s nutritional knowledge gaps. However, it is difficult to absorb a large body of nutritional literature in a short period of time. Sometimes providing a few new key concepts at each visit, with related specific goals for change and handouts reinforcing those concepts, can lead to success from visit to visit.

Discussing each concept and applying them to current nutritional intake helps shape patient eating and exercise behavior. It is especially useful when the clinician and the family are trying to create a gradual evolution of change and not expecting changes to occur all at once. In addition, consultation with a nutritionist who can analyze food records, explain those analyses, and make specific recommendations for change can be extremely helpful in designing a strong behavioral plan.

Misinformation/Information About Physical Activity

Most overweight youths’ physical activity levels are insufficient (Frenn & Malin, 2003). Talking with these children and adolescents about why they do not “just move” exposes a host of barriers. “Cardiovascular fitness,”"strength training,” and “flexibility” are not well understood as important goals for physical fitness. Furthermore, parents focus on more traditional, adult-oriented exercise options like aerobics classes, treadmills, running, etc. While these are certainly legitimate types of exercise, they can be intimidating to youth who are not accustomed to being active, or these are simply boring for children.

Instead, patients need to be provided with more child-friendly options (hopscotch, jumping rope, playing at the playground, tag with friends, etc.) or adolescent-friendly options (dancing to their favorite music, double dutch, etc.). In short, if the youth enjoy what they are doing, they are more likely to stick with it. The goal of the clinician, then, is to help the patient and their family get creative and brainstorm options for physical activity that the patient is willing to try.

One way to brainstorm with the family is by making a list, with the child’s input, of all the activities they currently enjoy, then providing a list of other potential activities that seem to interest the child, so they have a variety of both new and familiar activities to choose from. There are handouts available that list low-cost/ no-cost options appropriate for different settings (in house, out of house, with others, solitary, etc.) and different weather conditions (Ward-Begnoche & Gance-Cleveland, 2005). A list of local resources also can be helpful. Sometimes doing several short bursts of physical activity is more logistically possible than one long session, and it may be more reinforcing (Epstein et al., 2001). The main goal of these suggestions is to provide fun, easy ways to increase physical activity. Simply providing the patient with interesting exercises, however, is not enough to make actual changes in behavior. One technique for encouraging exercise is making sedentary activities (computer time, TV time, etc.) contingent upon completion of physical activity (Goldfield, Kalakanis, Ernst, & Epstein, 2000) or pairing physical activity with something fun (alone time with a parent, having a play date at the park, etc.). Also, community-based solutions can be helpful for many individuals who are not interested in creating their own exercise regimens. Pate et al. (2005) found that physical activity among high school girls was successfully increased via a school-based intervention program. While taking into account the child’s preferences or desired physical activities is helpful in maintaining motivation and interest in being active, sometimes it takes more than just encouragement to elicit the needed changes, and more creative solutions are necessary. With patience and creative brainstorming, there is a solution that works for every situation (Sallis, Prochaska, & Taylor, 2000).

Goal Setting

For both the patient and the clinician, understanding the goals of treatment and how to approach them is critical. Practitioners, parents, and patients often focus on weight loss as the primary goal. This, however, can be a frustrating and elusive goal. Many times, weight loss occurs slowly and is often not immediately achieved, so patients interpret their treatment plan as being unsuccessful.

Treatment goals should focus instead on changes in eating and activity behaviors; these changes will provide more appropriate signs of treatment success for three reasons.

First, even if a child maintains their weight after making changes to their diet and exercise, they will often grow in height. This will improve their BMI over time even if the numbers on the scale do not change much. Numbers on the scale are not the best indicator of improved weight status for children who are still growing.

Second, even in adolescents who have finished growing, weight loss may not occur quickly enough to motivate the patient to stick with the behavioral changes. Further, youth may focus on weight as the goal and not on the behavioral changes themselves, limiting the breadth of changes that could be made and reducing the likelihood of success.

Third, increased physical activity and nutritional status will likely have immediate health benefits (such as cardiovascular and pulmonary functioning, muscle strength, improved immunological functioning, etc.) even if weight loss is not immediately achieved.

Clinicians and patients often set goals that are too broad or vague to give patients and families specific practical changes to apply at home. Refer to Table 1 for examples of nonspecific, vague goals and more specific target behaviors.

Some goals improve positive health-related behaviors (exercising more, eating more fruits/vegetables, etc.) rather than just reducing negative health-related behaviors (eat less fat, smaller portions, less screen time, etc.). This provides a balance of increasing some behaviors while decreasing others, which is important in goal setting. Goals should start small and build over time toward final target goals.

One way to monitor behavioral changes and patient progress is to track the changes in eating and exercise at each clinic visit. Graphing behavioral changes can provide a visual depiction of change that is rewarding to patients, especially those who have not seen much weight change as yet. Goals must be specific and measurable, however, to be graphed. Journaling is often required for this level of monitoring but can be simple and easy, such as keeping a notebook in a purse or backpack. If more resources are available, computer joumaling with email reminders to journal, a nurse or other professional calling in the evening, etc., may be helpful.

Journaling and/or graphing will help practitioners, parents, and patients successfully evaluate progress toward healthy eating behaviors and promote a positive attitude and dialogue. This also can provide a monitor for any nutritional deficiencies, like calcium intake, or low vitamin D levels, which is so important to children who are still growing. Frequent visits with positive, nonjudgmental encouragement for changes and continued energy to maintain changes helps prevent patients from getting discouraged when the numbers on the scale do not change quickly.

Figures 1, 2, and 3 show examples of various stages of treatment (baseline, treatment, maintenance). It is important to remember that plain graph paper with handwritten columns or even dots works just as well as computer-generated columns. Limiting target goals to between one and three helps keep practitioners, parents, and youth focused on the specific target goals they are working on from visit to visit. When one goal area is achieved and maintained over 2-3 months (suggesting it has become “habit”), then another goal can replace it as a target behavior.

Goals should be assessed and revised at each visit, depending on the ability of the patient to reach the goals made from the last visit, working progressively toward final target goals. When goals are not met, asking the patients “why” in a nonjudgmental manner can uncover individuals’ unique barriers and lead to problemsolving discussions that create new strategies for success (see Table 2).

Summary

Addressing weight status and related nutritional and activity behaviors is difficult if potential barriers are not assessed and treated alongside them. Multiple barriers are possible, including misinformation about eating behaviors, activity behaviors, and reasonably attainable goals. Therefore, treatment of overweight children and adolescents needs to include an assessment of barriers to change and the development of strategies to surmount them. An individualized treatment plan is needed to take into account the unique combination of issues, like those noted above, that may impact the types of recommendations made and the level of success that is likely to be achieved.

Search terms: Barriers to change, behavioral pediatrics, compliance, nursing assessment, overweight youth, pediatric obesity

References

Bish, B., & Gottesman, M. M. (2005). Teaching parents about portion sizes for preschoolers. Journal of Pediatric Health Care, 19, 54-57.

Bryant, R., & Dundes, L. (2005). Portion distortion: A study of college students. Journal of Consumer Affairs, 39, 399-408.

Byrd-Bredbenner, C., & Schwartz, J. (2004). The effect of practical portion size measurement aids on the accuracy of portion size estimates made by young adults. Journal of Human Nutrition and Dietetics, 17, 351-357.

Epstein, L. H., Paluch, R. A., Kalakanis, L. E., Goldfield, G. S., Cerny, F. J., & Roemmich, J. N. (2001). How much activity do youth get? A quantitative review of heart-rate measured activity. Pediatrics, 108, e44.

Frenn, M., & Malin, S. (2003). Diet and exercise in low-income culturally diverse middle school students. Public Health Nursing, 20, 361-368.

Goldfield, G. S., Kalakanis, L. E., Ernst, M. M., & Epstein, L. H. (2000). Open-loop feedback to increase physical activity on obese children. International Journal of Obesity, 24, 888-892.

Pate, R. R., Ward, D. S., Saunders, R. P., Felton, G., Dishman, R. K., & Dowda, M. (2005). Promotion of physical activity among highschool girls: A randomized controlled trial. American Journal of Public Health, 95, 1582-1587.

Sallis, J. F., Prochaska, J. J., & Taylor, W. C. (2000). A review of correlates of physical activity of children and adolescents. Medicine and Science in Sports and Exercise, 32, 963-975.

Ward-Begnoche, W., & Gance-Cleveland, B. (2005). Promoting behavioral change in overweight youth. Journal of Pediatric Health Care, 19, 318-328.

Wendy L. Ward-Begnoche, PhD

Assistant Professor of Pediatrics

Department of Pediatrics, section of Pediatric Psychology

College of Medicine, University of Arkansas for Medical

Sciences

Arkansas Children’s Hospital

Little Rock, AR

Julia Thompson, BA

Graduate Student

Department of Psychology

Louisiana State University

Baton Rouge, LA

Author contact: wardbegnochewendyl@uams.edu, with a copy to the Editor: roxie.foster@UCDenver.edu

Copyright Nursecom, Inc. Jul 2008

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