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Parents' integration in the treatment of adolescents with obesity: a qualitative study.

Introduction: Obesity during adolescence is particularly challenging. Our aims were to identify parents' and adolescents' perceptions regarding obesity, as well as family dynamics before and after family-based behavioral therapy (FBBT) to improve obesity. Method: Using a qualitative approach, 23 parents and 21 adolescents aged 12 to 18 years participated in 6 focus groups, before and after FBBT. Focus groups were audio-taped, transcribed verbatim, and analyzed using content analysis. Results: Transcript analyses suggested 3 major themes from both adolescents and parents: obesity as a source of strong negative emotions, adolescents and weight-control responsibility, and disruption in family dynamics. FBBT improved self-confidence and family functioning, allowing for behavioral changes. Both adolescents and their parents felt empowered. Discussion: Family dynamics are an important issue in weight-loss treatment during adolescence. Including both parents and adolescents in therapy is crucial for tackling obesity and addressing health needs related to this age group.

Keywords: adolescent, parents, obesity, family dynamics, behavioral therapy

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Obesity in adolescence, defined by the World Health Organization (WHO) Growth Reference (de Onis et al., 2007) as a body-mass index (BMI) of more than 2 SDs above the mean, is a serious health problem with substantial physical and emotional complications, which may lead to chronic diseases later in life (Anderson, Cohen, Naumova, Jacques, & Must, 2007; Gungor, 2014; Gurnani, Birken, & Hamilton, 2015; Halfon, Larson, & Slusser, 2013; Maggio et al., 2014). Obesity at this age is caused by multiple factors, including individual, family, and environmental factors. Among family factors, parenting style appears to affect adolescent health behaviors and weight (Andriani, Liao, & Kuo, 2015; Bauer, Neumark-Sztainer, Fulkerson, Hannan, & Story, 2011; Berge, Wall. Loth. & Neumark-Sztainer, 2010; Erkelenz, Kobel, Kettner, Drenowatz, & Steinacker, 2014; Zarychta, Mullan, & Luszczynska, 2016), as well as negative life events related to family health (Lurneng et al., 2013).

Guidelines for obesity interventions in children and adolescents recommend comprehensive treatments combining dietary intervention, behavioral approaches, and physical activities, which have shown to have beneficial effects on adiposity (Hoelscher, Kirk, Ritchie, & Cunningham-Sabo, 2013; Luttikhuis et al., 2009; Whitlock, O'Connor, Williams, Beil, & Lutz, 2010). Targeting parents is also an important compo nent of the treatment and family-based programs have been widely developed (Epstein, Valoski, Koeske, & Wing, 1986; Epstein, Valoski. Wing, & McCurley, 1994; Flodmark, Ohlsson, Ryden, & Sveger, 1993; Golan, Weizman, Apter, & Fainaru, 1998; Golley, Magarey, Baur, Steinbeck, & Daniels, 2007; Ho et al., 2012; Kitzmann et al., 2010; Sung-Chan, Sung, Zhao, & Brownson, 2013; Tanas, Marcolongo, Pedretti, & Gilli, 2007). Most of these programs have involved work on improving parental modeling and positive parenting styles, such as child-management strategies and authoritative parenting.

However, most of these studies have been conducted with children; very few have targeted adolescents age 12 and older (Brownell, Kelman, & Stunkard, 1983; Coates, Kilien, & Stunkard, 1982; Kitzman-Ulrich et al., 2009; Nowicka & Flodmark, 2008). Involving parents in a program for adolescents can be challenging, as adolescents are developing autonomy, moving toward being less dependent on their parents. For the same reason, it may also be difficult for these parents to understand the importance of their involvement in a weight-loss program for their growing adolescents. Nevertheless, parental influence does not decline as the child progresses through adolescence and parenting style remains strongly related to many of these adolescent behaviors (Glasgow, Dornbusch, Troyer, Steinberg, & Ritter, 1997; Slicker, Billie, Picklesimer, & Fuller, 2005).

Other studies have assessed adolescents with obesity and their parents' perceptions of their weight problems, as well as their motivations or barriers to participate in multidisciplinary therapies for obesity; less emphasis has been placed on understanding family dynamics and parents' perceptions of their inclusion in these therapies (Amiri et al., 2011; Jackson, Wilkes, & McDonald, 2007; Lachal et al., 2013; Lindelof, Nielsen, & Pedersen, 2010; Murtagh, Dixey, & Rudolf, 2006; Pocock, Trivedi, Wills, Bunn, & Magnusson, 2010; Stewart, Chappie, Hughes, Poustie, & Reilly, 2008). Qualitative studies are a good way to evaluate familial dynamics and how therapies are experienced by both patients and their parents, providing health-care professionals with a better understanding of family needs around obesity.

The purpose of this qualitative study was to explore parents' and adolescents' perceptions of their adolescents' obesity, as well as family dynamics around this issue before and after participating in a multidisciplinary family-based behavioral therapy for obesity (FBBT).

Method

We conducted a qualitative study using focus groups to obtain in-depth descriptions of adolescents and parents' perceptions of their adolescents' obesity, as well as family dynamics around this theme (Rich & Ginsburg, 1999).

The study sample was taken from a population of adolescent patients (12-18 years) who visited our obesity clinic at the Geneva University Hospital in Switzerland from 2009-2010, and who agreed to participate in an FBBT. Patients were referred to our center by general practitioners, pediatricians, and school nurses or parents. Inclusion criteria for participation in a group program were: (a) to be obese (i.e., BMI more than 2 SDs higher than the mean) for age and sex using the WHO Growth Reference; de Onis et al., 2007), (b) to have at least one parent willing to participate in the program, (c) to be fluent in French, (d) to not be suffering from any psychiatric disorder, and (e) to be motivated to participate in the program (assessed by a psychologist).

Description of the Family-Based Behavioral Program

The program aimed to encourage lifestyle changes in therapeutic groups over a 5-month period. Adolescents and parents took part in psychoeducation sessions of 90 min once a week conducted by a dietician and a psychologist certified in cognitive-behavioral therapy. The program used an integrative approach, including psychoeducation, stimulus control, behavioral awareness, setting small objectives for behavior change, and role-play. A family therapist supervised the team. The program also included 90 min of physical activity twice a week for the adolescents. The parents' program consisted of nutrition-related topics and systemic interventions to facilitate family functioning by reinforcing family resources and improving the emotional climate for adolescents with obesity (Flodmark et al., 1993).

Sampling and Participants

All parents and adolescents included in the program were invited to participate in a focus group before and after taking part in the program. Forty-four parents and adolescents participated in six focus groups: 21 adolescents (62% girls) and 23 parents (91% mothers). Group size ranged from five to 11 participants. For the focus groups, we divided groups by adolescent age, similar to the treatment groups, ages 12-14 and 15-18 years. Characteristics of participants are described in Table 1.

We obtained written consent from the parents and the adolescents to allow recording and transcription of the focus-group discussions. Only one mother refused to participate in the study. The study protocol was approved by the Geneva University Hospital's Clinical Research Ethics Committee.

Focus Groups and Data Collection

Focus groups were held a week before and after the program in a meeting room at the hospital. Adolescents and parents were in separate groups. All focus groups were conducted in French, audio-taped, and lasted 90 min. Two facilitators, unknown to participants, not involved in the program, and experienced in conducting focus groups with adolescents, moderated the focus groups. Program therapists were not present.

The research team developed four openended questions based on literature review and clinical experience. The questions explored obesity perceptions, family dynamics, and participation in FBBT, which were used to frame the discussion: (a) "How do you deal and cope with your obesity (patient)/your child's obesity (parents)?" (b) "What are family interactions like?" (c) "What can you say about your/your child's well-being?" (d) "What do you think about your future participation/participation in the program?"

Data Analysis

The recordings were anonymously transcribed verbatim. To analyze the data, we applied the content-analysis approach (Hsieh & Shannon, 2005). Three of the authors independently read all transcripts several times and carried out open coding of quotes relevant to the aim of the study. They then compared and discussed their codes until they reached consensus. Similar coded quotes were grouped in categories to determine relevant key themes.

A native English speaker translated and back-translated quotes into English and French to ensure good quality of translation for this article.

Results

The thematic content-analysis process identified three key themes from both adolescents' and parents' focus groups: Obesity as a source of strong negative emotions in parents and adolescents; parent and adolescent responsibilities for controlling weight; and family dynamics and obesity during adolescence. They are described below, and illustrated with verbatim quotes.

1. Obesity as a Source of Strong Negative Emotions, Both in Parents and Adolescents Obesity raised strong feelings in adolescents. "People don't realize what it feels like to be obese ..." (14-year-old boy).

"Weight is not a problem like others because it shows physically, everybody can see it, and we often don't feel well mentally" (13-year-old boy).

Having a child with obesity was also emotionally difficult for the parents. Some of them felt that family members, friends or even strangers, judged them as incompetent parents.

"It is as if people think we don't care!" (mother of a 16-year-old girl).

"It's like they think we don't have the money, to make our daughter eat in a healthy way" (mother of a 14-year-old boy).

The FBBT helped to relieve these adolescents and their parents by giving them the opportunity to share their difficulties with the group and find mutual support.

"To be part of a group and meeting people with the same problem like us, we don't feel alone anymore ... and it brings confidence" (mother of a 14-year-old girl).

"I'm not the only one who can't achieve it with my daughter, who doesn't have a solution, and that really helps me" (mother of a 16-year-old girl).

"I felt alone in life. I felt fat and ugly. Since coming here, I do not think that anymore. I'm just like everyone else ... What's important is that I feel good about myself' (17-year-old girl).

2. Weight Control: Parent and Adolescent Responsibilities

Before participating in the FBBT, parents felt helpless and lacked personal resources to address their children's obesity. They reported having tried many strategies with no success and felt discouraged.

"For six months I have been locking up all the food, because she was eating it all" (mother of a 13-year-old girl).

"We tried everything: to hide food, to be nasty, even blackmail" (mother of a 14-year-old boy).

Parents expected their children to be responsible and to adopt healthy eating to lose weight. They considered themselves as already fully supportive.

"... to be able to control himself! What I am doing for him now, he has to be able to do it" (father of a 15-year-old boy).

"I want him to grow up, to learn how to eat and to cope with his life" (mother of a 16-yearold boy).

Many parents did not know what role they should play in their children's treatment, especially when entering adolescence. They relied on professionals and the group's support to enhance their children's motivation.

For the adolescents, the constant control of their parents on their eating habits discouraged them.

"Sometimes, I walk through the kitchen and my mom says: 'stop, don't do that!' Even if I didn't plan to eat anything. That irritates me" (13-year-old girl).

"My parents tell me not to eat this or that. I'm fed up, I feel discouraged" (13-year-old girl).

Some felt they were treated like irresponsible children.

"My mom is always watching me, she checks everything I eat. She doesn't understand that I can cope by myself. She has done this for such a long time, it's become a habit" (15-year-old girl).

FBBT helped parents understand their roles in their adolescents' behavior changes. They realized that obesity was not only about their children's willingness to change, but also about their children's well-being and emotions, which can interfere with their willingness to make efforts. They understood that family dynamics have a role to play in supporting this well-being.

"I thought that it was a matter of will and that he had to make the first step. I then realized, through these discussions, that I also have a role to play to make things better" (parent of a 16-year-old boy).

Parents noted an improvement in their children's empowerment, and recognized their capacity for making changes.

"Now I can see her like other adolescents" (mother of a 13-year-old girl).

"She is capable ... before, some biscuits for the afternoon snack were a drama, now, I say, ok you manage your own thing" (mother of a 14-year-old girl).

Likewise, adolescents felt more responsible and mature.

"It helps us to take a step forward, to see things in a different way, to grow up" (16-yearold boy).

"I don't know if I can say I'm more mature, but I feel I'm more responsible" (15 years old girl).

FBBT helped many parents and adolescents realize that both were responsible for achieving weight control: parents had to provide adolescents with an appropriate physical and emotional environment and show more confidence in their children's capacity to cope with obesity; adolescents had to take more responsibility and be confident in their ability to make changes.

3. Family Dynamics and Obesity During Adolescence

Many parents expressed concerns about the growing autonomy of their children and their eating without parental control. They attempted to overcontrol their children's eating and physical activities, which became a major source of conflict, particularly at mealtimes, and adversely affected family dynamics.

"There are many conflicts. Always behind her saying: don't eat that, you have enough, don't open the fridge!" (mother of a 13-year-old girl).

"We have so many conflicts to the point where we don't speak to each other anymore" (15-year-old girl).

"My mother yelled at me because of my weight" (12-year-old boy).

FBBT helped parents and adolescents have better relationships and improve family dynamics.

"I understood that my role was not about systematically entering into a conflict about food ... our relationship has changed" (mother of a 16-year-old girl).

"A kind of trust has been established: the trust she expected from us and the one we expected from her" (mother of a 15-year-old girl).

"We communicate better" (mother of a 17-year-old girl).

"We now have quiet meals with no conflicts and that has really changed" (13-year-old girl).

"Things are better now. Mealtimes used to be full of conflicts. As I was upset, I didn't appreciate what 1 was eating or would take my revenge on food and eat twice as much because I was angry!" (16-year-old girl).

Discussion

These results highlight some important findings on how adolescents and their parents perceive obesity, its effects on family dynamics, and the benefit of FBBT. To our knowledge, this is the first study on parents' and adolescents' perceptions of their inclusion in an FBBT program and family dynamics around obesity at this age.

Obesity raised a number of challenges for these families, and weight loss was not the only issue motivating them to participate in the pro gram. These families (both parents and adolescents) felt powerless in the face of obesity. Including the parents in the therapy enabled a number of changes that were observed, both among parents and adolescents. Changes in parents have supported those in adolescents and vice versa, underlying the importance of including parents in the therapy. Before the therapy, parents put the focus on the adolescent: She/he was the one who had to make the changes and take control over her or his food intake and physical activities. These results are supported by another qualitative study conducted during a weight-loss summer camp in Denmark, in which parents were interviewed about their children's obesity and treatment, but were not themselves enrolled in the treatment (Lindelof et al., 2010). These parents also perceived themselves as already fully supportive, criticized their children for not being engaged in healthier behaviors, and did not feel the need to be more supportive. In our study, the adolescents were torn between their perceived inability to control their food intake worsened by the constant monitoring of their parents, and their desire for responsibility and autonomy. They reported that this constant monitoring was discouraging and contributed to their loss of confidence in their capacity to make changes and actually increased their desire to eat. This underlined the need to take into account family dynamics as a component of weight-loss interventions.

Adolescents with obesity aroused strong negative emotions in family members. There are some similarities with families of patients with anorexia, as described by Treasure et al. (Treasure et al., 2001,2008). Parents' own feelings of helplessness and self-blame for failing to help their children is translated into overt criticism of the person with anorexia, or with obesity, as in our context. In some families, these negative emotions may be expressed directly and confrontationally through blame, criticism, or hostility. The fights typically took place at the dinner table, as meals are the communicative focus within most families. In our study, family members frequently argued about food and weight in an attempt to control the obese child's food intake. Adolescents are often consequently hurt and may find consolation in food. Parents and adolescents reported being stuck in emotional reactions that inadvertently played a role in maintaining the obesity problem.

Previous studies on family functioning have revealed that family dynamics influence the physical, social, and emotional well-being of adolescents (Berge, Wall, Larson, Loth, & Neumark-Sztainer, 2013; Dinsmore & Stormshak, 2003; Wen, Simpson, Baur, Rissel, & Flood, 2011; Zeller et al., 2007). There are clear associations between better family functioning (e.g., communication, closeness, problem solving, interpersonal relationships) and positive health behaviors in adolescents. Targeting family dynamics is therefore an important goal of obesity therapy during adolescence, as it can bring fewer conflicts to adolescent-parent relationships, resulting in fewer emotional eating events. Improving family functioning, especially during adolescence, will also help support behavioral changes. Accordingly, there is an enhancement of self-confidence and motivation for care, leading to improved continuity of care (de Niet, Timman, Jongejan, Passchier, & van den Akker, 2011; Luttikhuis et al., 2009). Focusing less on food can help families address other aspects of adolescence, such as empowerment.

The group support was beneficial for both parents and adolescents: Sharing information, developing social skills, imitating behaviors and instilling hope were very helpful for all of them. Such effects are of particular interest with regard to obesity, which can lead to negative peer relationships, discrimination, low self-esteem, and feelings of isolation among adolescents and their parents (Latner & Stunkard, 2003).

The main limitations of our study were, first, that our patients were self-selected with a particular interest in FBBT and thus may not be representative of all obese adolescents and their parents. Second, the families who participated in the therapy and in this research are likely to be relatively highly functioning. They had to show a certain level of organization and cohesion to be able to participate in the program and to complete it over the course of 6 months. Third, very few fathers took part in the focus groups, and they may have another perception of the situation. Finally, this study included only adolescents with obesity (i.e., those whose BMI was in > the 97th percentile of their age group), and findings may not apply to youth who are overweight with a lower BMI.

This qualitative research highlights the importance of including both parents and adolescents in adolescent weight-loss therapy until at least the age of 18. The management of obesity during adolescence generates strong emotions in families, which, to foster healthy family dynamics that will contribute to the implementation and maintenance of behavior changes, need to be addressed. Parents have a complex influence on their children's lifestyle changes that goes far beyond just promoting healthy habits. This study also demonstrated that the standard measure of obesity therapy's success (i.e., BMI) is limiting, as major changes take place in family relationships, such as personal improvements and quality of life, which are not necessarily directly related to weight loss. Health professionals working with patients with obesity need to consider other outcomes, such as mental and social well-being, as well as family interactions, in addition to metric criteria, such as the BMI.

http://dx.doi.org/10.1037/fsh0000219

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Received September 28, 2015

Revision received June 27, 2016

Accepted June 27, 2016

Catherine Chamay Weber, MD, Nadia Camparini, MPsy, Lydia Lanza, MPsy, and Francoise Narring, MD, MSc

University Hospitals of Geneva and University of Geneva

This article was published Online First September 5, 2016.

Catherine Chamay Weber, MD, and Nadia Camparini, Adolescent Medicine Unit, Adolescent and Young Adult Program, Department of Child and Adolescent and Department of Community Medicine, Primary Care and Emergency, University Hospitals of Geneva, and Department of Pediatric, University of Geneva; Lydia Lanza, Exercise Medicine, Paediatric Cardiology Unit, Department of Child and Adolescent, University Hospitals of Geneva, and Department of Pediatric, University of Geneva; Franfoise Narring, MD, MSc, Adolescent Medicine Unit, Adolescent and Young Adult Program, Department of Child and Adolescent and Department of Community Medicine, Primary Care and Emergency, University Hospitals of Geneva and Department of Pediatric, University of Geneva.

The authors thank Christina Akre and Damien Weber for their English review of the manuscript. This study was supported by the Wilsdorf fondation, Geneva, Switzerland.

Correspondence concerning this article should be addressed to Catherine Chamay Weber, MD, Adolescent Medicine Unit, Adolescent and Young Adult Program, Department of Child and Adolescent and Department of Community Medicine, Primary Care and Emergency, University Hospitals of Geneva, Rue Willy-Donze 6, 1211, Geneva 14, Switzerland. E-mail: Catherine.chamayweber@ hcuge.ch
Table 1
Characteristics of Participants

Group                         Variable               n

Adolescents                   Boys                    8
                              Girls                  13
                              Mean age (years)       14
                              Body-mass index > 97   21
Parents                       Fathers                 2
                              Mothers                21
Parents' country of origin    Switzerland             8
                              Other country          15
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Author:Weber, Catherine Chamay; Camparini, Nadia; Lanza, Lydia; Narring, Francoise
Publication:Families, Systems & Health
Article Type:Report
Date:Dec 1, 2016
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