For several hours we talked about obesity with the resident doctors at the local family clinic. After covering the typical recommendations for losing weight, such as eating healthy and increasing exercise, Dr. B informed us of the most practical treatment method they use. “I usually ask the patient to complete a food journal.”
According to Dr. B and the other residents, a journal can provide concrete evidence of successes and areas in which adolescents could improve their diets. So we asked about the success of such an assignment. Dr. B chuckled and said, “I’ve never had a patient complete a food journal.”
As soon as he said this, two other doctors in the room added their own experiences. One echoed Dr. B’s statements, and the other told his one and only success story:
“The patient was fourteen years old. He didn’t like how big he was becoming and decided to play sports. After he started playing sports he lost thirty pounds.”
As we explored the issue of adolescent obesity within our community, we found that while the recommendations for losing weight may appear simple, successful results were not easily obtained. Our goal was to better understand the prevalence and treatment of adolescent obesity through patient observation and interviews with resident doctors in this mid-Western city.
During our semester-long research, we examined the three main influences related to adolescent obesity: familial, social, and environmental. The results below express how residents view the problem of obesity among adolescents who live in lower socioeconomic circumstances. We also examine how text messaging might be a better way to build a behavioral health intervention for these adolescents.
“It’s just not all that surprising when obese children have obese parents…”
Until they leave home, most adolescents are dependent on their parents for food and nutrition. Adolescents do not have much influence in what foods are provided and what meals are cooked. If the parents fail to provide healthy options on a consistent basis, an adolescent’s overall health will likely suffer, and his or her probability of becoming obese increases.
The residents we interviewed commented that the role a parent plays as a provider for their children is closely connected to the development of that child’s health. They developed this point by saying that it is difficult for parents with lower collective incomes to provide as many healthy choices as parents with higher incomes. This is due to the fact that processed foods and fast food items tend to be less expensive than healthy food options. This socioeconomic factor makes the family’s influence on adolescent obesity even more complex.
The probability of adolescents becoming obese is also influenced by the parents’ own habits. One resident said the “parents are key” – changing the behavior of parents will effect change in their children. Rather than the typical lecture to eat better, which residents called “do as I say, not as I do”, parents should model “do as I say AND as I do”. In other words, parents should tell their adolescents how to eat and exercise in a healthy way while also eating well and exercising themselves. It is important for adolescents to see the advice their parents give them put into action because they are more likely to learn through example.
“There is a reason why heavier kids don’t go out for sports, such as the swim team… they care about how their peers view them.”
The doctors stated that peers are more influential than parents regarding behaviors affecting weight. While parents control home life, peers influence life outside the home through social groups, which is of significant importance during adolescence. In particular, peers influence the adolescent’s body image. The doctors believed that obese adolescents are particularly susceptible to developing a negative body image, which, they say, may lead to feelings of isolation and depression.
Doctors cited poor self-esteem as a causative factor and product of negative body image. Overweight and obese adolescents are often less outgoing because they do not want to draw attention to themselves. The doctors agreed that their overweight and obese patients were not in the “type” of crowd to play sports, which could aid in losing excess weight.
Isolation, depression, and low self-esteem can also lead to destructive behaviors, such as involvement in drugs, alcohol, smoking, and sexual activity. The doctors stated obesity takes a backseat to the more “immediate” issues of sex and drugs, as well as acute care problems like the flu. With these problems in the foreground, doctors often do not have the time to address weight issues.
“These kids just don’t have the same opportunities to go out and play as they should.”
Our community suffers through 6 months of cold, often bitter weather. Most outdoor activities are simply out of the question for half of the year. Even when the snow has disappeared, outdoor exercise is questionable. The city suffers from both a lack of sidewalks and crime, discouraging people from walking or running.
Dr. H also stressed that the lack of gym class in middle and high school significantly influences adolescents’ weight. As both students and faculty in schools often overlook health classes, the importance and effort needed for healthy lifestyles is neglected. Additionally, the lack of neighborhood youth programs prevents access to organized sports from even the most motivated kids. Given the adolescents’ socioeconomic backgrounds, a gym membership is something that the residents of the community often do not have the luxury to afford.
Intervention: Food Journals to Texting
The increasing prevalence of adolescent obesity is a problem faced by the entire country. The Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity (2001) reported that adolescent overweight and obesity has become a nationwide problem as the prevalence of overweight adolescents has increased from 5% in 1976-1980 to 17.4% in 2003-2004, corresponding to 12.5 million individuals ages 12-19.
As an adolescent increases in weight, he or she also increases health risks, such as asthma, cardiovascular problems, diabetes, sleep apnea, hypertension, early maturation, orthopedic problems, and the psychological effects of social stigmatization. These facts demonstrate the importance of preventing weight gain, treating overweight and obesity, and improving one’s quality of life. As behavioral and environmental factors are large contributors to overweight and obesity, they provide the greatest opportunity for intervention (Call To Action, 2001; see also the Center for Disease Control’s page on obesity).
According to Dr. K, 20-30% of his adolescent patients are overweight or obese. When he tries to help, the patients are either “noncompliant” or their lifestyles are not conducive to healthy changes for many of the reasons covered above.
One of the most common treatment methods doctors instruct overweight or obese adolescents to do is to keep a food journal because it is relatively easy and has been shown to work. For a period of four to seven days, the adolescent writes down everything he or she eats. After that week, the patient comes back in to the clinic for a follow-up visit to discuss his or her diet and nutrition.
Keeping a food journal has proven to be a mildly successful treatment method in our community, largely because patients either fail to make a follow-up appointment or don’t complete the food journal. However, we believe many of the ideas behind the food journal approach can be adapted to a medium that adolescents already use: text messaging.
The majority of adolescents in America have cell phones and use them constantly to text message. The idea we propose is for the patient to text everything he or she eats to a responsible party in the clinic, such as a dietician. The responsible party could keep track of the patient’s meals for him or her, so the only responsibility the patient has is to text in the meals and make a follow-up appointment. To reduce the risk of forgetting to text in a meal, an automated text messaging service could be implemented to send reminders to patients participating in this program.
Despite all the barriers and influences facing obese adolescents, we believe a relatively simple texting program can significantly increase the number of success stories in our community. T9, abc, or qwerty, adolescent obesity will be yesterday’s text.