Original Article

Adolescents’ Preferences for Social Support for Healthful Eating and Physical Activity Bridget K. Biggs, PhD,* Jocelyn Lebow, PhD,*† Christina M. Smith, LPN,‡ Kelly L. Harper, BA,§ Christi A. Patten, PhD,‡ Leslie A. Sim, PhD,* Seema Kumar, MD\ ABSTRACT: Objective: This study explored adolescents’ views on the sources and types of social support they would prefer when trying to eat more healthfully and be more active, as well as their opinions regarding means of enhancing social support in interventions. Methods: A total of 28 adolescents (14 males, 14 females) ages 13 to 18 years participated in 4 focus groups that were stratified by gender and age to enhance participation. Results: As expected, participants most readily named parents and friends as important sources of support and described wanting instrumental and emotional support from parents, companionship and emotional support from friends, and informational support from professionals. The focus groups revealed rich information regarding parents’ and peers’ behaviors that are and are not received as emotionally supportive, the helpfulness of parents’ concurrent changes in lifestyle, and the importance of parents not ignoring or colluding with unhealthful behavior. Most participants expressed a need for frequent contact and a trusting relationship with professionals. Opinions were mixed regarding inclusion of others in appointments, use of electronic communications and social media, and group treatment formats. Conclusion: Results have implications for enhancing social support in behavioral weight management interventions that are developmentally relevant for adolescents. (J Dev Behav Pediatr 35:494–509, 2014) Index terms: pediatric obesity, health promotion, adolescence, social support.

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oncern about pediatric obesity has grown in the last three decades. An estimated 17% of youth ages 2 to 19 years are obese, defined as body mass index (BMI) at or greater than 95th percentile for age and gender; another 15% are overweight, defined as BMI at or above the 85th and below the 95th percentile.1 The importance of effective intervention before adulthood is underscored by the persistence of elevated BMI and the medical and psychological consequences of obesity. Few individuals overweight during adolescence have a BMI in the healthy range during early adulthood.2 Furthermore, childhood obesity is associated with comorbidities including type 2 diabetes, hypertension, dyslipidemia, sleep apnea, nonalcoholic liver disease,3 From the *Division of Child and Adolescent Psychiatry and Psychology, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; †Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL; ‡Behavioral Health Research Program, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; §Department of Psychology, University of North Carolina at Greensboro, Greensboro, NC; \Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Mayo Clinic, Rochester, MN. Received May 2014; accepted July 2014. Supported by the Mayo Clinic Department of Psychiatry and Psychology Small Grants Program with funding from the Mayo Clinic grant number UL1TR000135 as well as discretionary funds from the Mayo Clinic Department of Psychiatry and Psychology. Disclosure: The authors declare no conflict of interest. Address for reprints: Bridget K. Biggs, PhD, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins

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and early mortality in adulthood.3,4 Children with obesity also experience reduced quality of life5 and social marginalization.6 Interventions for pediatric obesity have been shown to lead to reversal or improvement of obesity-related comorbidities7 and improvements in quality of life.8 The mainstay of treatment for obesity in adolescents has been lifestyle modification with the aim of creating a negative energy balance through dietary modifications and increased physical activity. Although behavioral interventions seem to be helpful to adolescents, they do not have the same level of support as interventions for younger children.9–11 A potential key to establishing effective obesity treatments for adolescents may lie in meeting their unique developmental needs, particularly for social support to change eating and physical activity habits. Studies of adult weight management programs have demonstrated enhanced outcomes if participants use social support from friends, family, and romantic partners.12 For children, the most effective programs place a strong emphasis on parental involvement.13–15 It is likely that adolescents benefit most from social support that differs developmentally from optimal support for children and adults. Existing adolescent programs vary widely in degree of parent involvement, with mixed results regarding how parents can be involved for best treatment outcomes.10,16 These mixed findings make sense given that, although parents remain important, adolescents seek greater closeness and support Journal of Developmental & Behavioral Pediatrics

from peers.17 Perhaps fitting with the importance of peer support, adolescent behavioral weight management programs are most commonly delivered in a group format with other adolescents.16 One study demonstrating the benefit of peer-based adventure therapy added to a standard group-based weight management program suggests that enhancing peer support could contribute to improved treatment outcomes.18 Social support specific to weight loss has been studied in adult populations,6,19 with commonly identified types of support including emotional (i.e., encouragement and conveying concern), instrumental (i.e., provision of tangible goods and actions), appraisal (i.e., feedback regarding efforts, especially recognition of achievement/ effort), and informational (provision of relevant information). Although social support for physical activity has been found to correlate with adolescents’ level of physical activity,20 studies exploring the types of support adolescents desire for healthful eating and physical activity are lacking. Studies of adolescents with diabetes indicate that they tend to seek emotional support from both parents and peers but that they seek greater instrumental support from parents and greater companionship support (i.e., doing activities together) from friends.21,22 Before social support enhancement strategies can be tailored for adolescent weight management interventions, a good understanding is needed of the people, who adolescents believe, would be helpful and the types of support they would prefer from these individuals. Also, considering that adolescence is a time of transition from family-based care to establishing independent relationships with health providers and considering adolescents express a need to feel supported by health providers as they transition to adult care,23 it is important to clarify adolescents’ opinions regarding how professionals can be most supportive and how interventions can be delivered to optimize social support for lifestyle change. Little is currently understood regarding the professional behaviors that adolescents would find supportive. Regarding intervention delivery, including trusted friends and other peers is a potential avenue of enhancing social support for behavior change, considering the salience of peers during adolescence.17 Electronic communications are another potential avenue for enhancing social support for health behavior change. The Internet and social media are platforms that adolescents commonly use to connect with others, particularly peers,24,25 and such technology has received recent attention as a potentially helpful tool in the treatment of adult obesity.26,27 This study used focus groups comprising adolescents with elevated BMI (overweight or obese) to identify the sources, types, and avenues of social support adolescents would prefer when making lifestyle changes for weight management. We anticipated that adolescents would most readily name parents and friends as sources of support and would demonstrate beginning awareness of professionals as resources. We further hypothesized that Vol. 35, No. 8, October 2014

the types of support desired would vary by relationship, with adolescents preferring instrumental and emotional support from parents, companionship and emotional support from friends, and informational support from professionals. Regarding support in the context of interventions, we thought that adolescents would request ownership of the process independent of parents and might prefer to participate in interventions with friends or other peers. Finally, we expected that adolescents would prefer receiving intervention-related support through electronic means over more traditional avenues such as appointments with health care providers.

METHODS Study Design As the first step in this line of research, we used a qualitative approach to gain understanding of the issues and themes that could inform future quantitative studies.28 After recommendations from Krueger and Casey,29 focus groups were used to explore adolescents’ openended comments on an understudied topic for which they may have differing views than adult professionals or researchers. We anticipated that theme saturation would be achieved after 3 to 4 focus groups30 and grouped participants by age and gender to facilitate ease of participation.29 The study was approved by the Mayo Clinic institutional review board.

Participants The participant pool was identified through a search of medical records by the Mayo Clinic Division of Biostatistics and Informatics to identify patients in the study age range (13–18 years) who had a documented body mass index (BMI) at or greater than the 85th percentile in the previous year. A total of 5967 adolescents were identified through this search. Of these, 391 were randomly selected from those living in the county where the study was conducted, stratified across age and gender, to receive an invitation letter followed by phone call screening. We presented the study as an opportunity to learn from participants how adolescents would like others to support them in healthful eating and physical activity habits. Of those contacted by letter, 48 replied indicating interest and 44 replied that they did not wish to participate. To be eligible, adolescents had to have endorsed during screening a desire to make behavior changes for health or weight or to have spoken with a professional about healthful behaviors. All participants had sufficient English proficiency to participate in the focus group discussion and complete a demographic questionnaire. Exclusion criteria included current or past eating disorder diagnosis, current diagnosis of psychosis or substance abuse, presence of a learning problem or developmental delay that would affect ability to read or provide written responses to questions, and seizure disorder. © 2014 Lippincott Williams & Wilkins

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In total, 28 adolescents participated ranging in age from 13 to 18 years of age; mean 5 15. To enhance participation,29 focus groups were stratified by age and gender: older females with age 16 to 18 years (n 5 6), older males with age 16 to 18 years (n 5 7), younger females with age 13 to 15 years (n 5 8), and younger males with age 13 to 15 years (n 5 7). Participants were predominantly white (n 5 24, 85.7%), with 2 participants (7.1%) identifying as Hispanic/Latino, 1 (3.6%) as Native American, and 1 (3.6%) as Biracial (Filipino and white). By adolescent report, highest level of parent education was quite high: 11 (39%) graduate degree, 11 (39%) bachelor’s degree, 3 (11%) associate’s or vocational degree, and 3 (11%) high school diploma. Eight participants (3 females and 5 males) had a BMI over the 95th percentile, and 19 participants (10 females and 9 males) had a BMI between the 85th and 95th percentiles, with an average BMI of 27.44 and average BMI percentile of 90.39. There was 1 participant who attended a focus group with a sibling and was later discovered not to have an elevated BMI. Blind review of the focus group transcript could not identify any participant who differed significantly in his or her responses. Participants’ self-evaluation of their weight was as follows: 2 (7%) thought that they were “very overweight,” 15 (54%) described themselves as “somewhat overweight,” and 11 (39%) stated that they were “about the right weight.” No participants rated themselves as “somewhat underweight” or “very underweight.”

Procedures All focus groups occurred in a conference room owned by the medical center and located in a nearby business building, lasted approximately 1 hour and were facilitated by a female pediatric psychology postdoctoral fellow who had been trained as a moderator. The study coordinator (a female) was present in the room to take notes, and participants were aware that the study PI (a female) was present behind a 1-way mirror. The consent/assent process informed all participants that the session would be audio recorded and transcribed. A semistructured moderator guide was developed for this study (Table 1). Participants completed a brief demographic questionnaire on which they reported racial and ethnic identification, current height and weight, perceived weight status, and parental education. Participants were remunerated $20 for study completion. No participants elected to leave the study. Adolescents’ age, gender, and most recently measured BMI were obtained from their electronic medical record.

Analysis Focus groups were audiotaped and transcribed verbatim. Nonverbal communication and other behavioral observations were written into the moderator’s and 496 Social Support and Adolescent Weight Management

observer’s field notes, identified, and coded. Theme saturation was reached by the fourth focus group, as determined by consensus of the 3 facilitators who were present for all groups.29 A team of 4 researchers (including the 3 present for the focus groups) independently identified themes and coded transcript content. QSR Nvivo 9 software was used to complete content analysis of focus group themes and to group similar participant responses. The coding team worked together to summarize themes and representative quotes in the tables presented. Final results represent consensus among coders.

RESULTS As expected, participants most readily identified family (especially parents) and peers (especially friends and teammates) as sources of support for healthful lifestyle changes. Professionals most readily identified were coaches and fitness trainers, although participants also had ideas regarding support from other professionals such as physicians and dietitians. Adolescents’ responses supported hypotheses regarding types of support desired within each relationship and included additional types of desired support. Regarding intervention enhancements, adolescents largely agreed that at least some autonomy from parents is desirable; however, discussion was mixed regarding the inclusion of peers and use of electronic media and communications. Tables 2, 3, and 4 summarize themes and illustrative quotations separated by social relationship. Table 5 presents themes and quotations related to enhancing social support within interventions.

Parents/Family Members Participants expressed interest in instrumental and emotional support from family. Five themes were predominant. Specifically, adolescents wanted parents to provide practical assistance, motivate/encourage and recognize their efforts, avoid negativity and nagging, make similar changes/lead by example, and not to ignore unhealthy habits. Healthful Eating All groups agreed that parental and family support was crucial in maintaining a healthful diet. Participants identified parents as particularly important providers of instrumental support, specifically for stimulus control by purchasing fruits and vegetables, not buying junk food, and preparing/eating meals at home. It was suggested that parents and siblings could additionally offer motivation or encouragement by recognizing when participants were successful in healthful eating and by reminding adolescents of their goals without nagging. Several participants clarified that effective encouragement respects adolescent choice and does not take the form of parent-to-teen directive. A substantial number of participants stated that it was helpful when family Journal of Developmental & Behavioral Pediatrics

Table 1. Focus Group Questions 1. General A. If you were trying to eat healthier, what kinds of help or support would you want or need? B. If you were trying to be more active or fit, what kinds of help or support would you want or need? C. If you were trying to eat healthier or be more active, who would you want to support or help you? 2. Type of support by person’s role A. Parents/family In what ways would you want your parents to support or help you? What would you want them to do or say? What could your parents do or say to help you feel good about your efforts? What other family members are important? What could they say or do to support or help you? What is most important for family members to do or say? B. What about getting support from other teens? In what ways would you want other teens to support or help you? What would you want them to do or say? What could other teens do or say to help you feel good about your efforts? Would you prefer help from friends or from teens who are trying to make similar changes, even if you do not know them as well? Would the types of support you would want be different or the same if it was from a friend versus a teen you did not know so well but was trying to make similar changes? What kind of support is most important to get from other teens? C. Are there any professionals you would want to support or help you? (Prompts: Doctor? Dietician? Fitness trainer? Counselor or psychologist? School teacher?) In what ways would you want _______ to support or help you? What would you want them to do or say? What could ___________ do or say to help you feel good about your efforts? (Prompt using these questions for each person identified, if needed) What kind of support is most helpful to get from professionals? D. Are there other people you would want to support you? What would you want them to do or say? 4. Means of support A. Some people get one-on-one support from their doctor or another health professional (like a dietician or health counselor) during an office appointment How might office visits be helpful or unhelpful? What could be done to make communication with health professionals most helpful? How could other people be included so that they could support what you worked on with the health care professional? (specify family and friends if examples are needed) B. Some people meet regularly (like once a week) with a group of people who are trying to develop healthy eating and exercise habits. Typically, these groups are led by a counselor, dietitian, or fitness expert who help group members learn about healthy habits and how to make them part of their lives How might such a group be helpful or unhelpful? What could be done to make such a group most helpful? How could people in your life be included so that they could support what you were working on in the group? (specify family and friends if examples are needed) C. Some people get eating and exercise information, ideas, and support electronically, such as from websites and chat rooms or use social media (like Facebook or texting) to communicate with others about their efforts How might these ways of getting support be helpful or unhelpful? What would you want electronic support to be like? Would you use an app or website to track your eating and exercise? Why or why not? Would you want others to see the information you have recorded? Why or why not? If so, who would you want to see the information? D. Are there any other ways you would want to communicate with people who are supporting you to eat healthy and be active? 5. Final question A. Is there anything else you think we should know about the support teens would want when trying to eat healthy or be active?

members shared participants’ healthful eating goals and “led by example.” Some noted the importance of parents “being on the same page,” stating that healthful eating was harder if one parent persisted with unVol. 35, No. 8, October 2014

healthful habits. Parents were viewed as more credible if they were eating healthfully themselves. Several participants noted that parents should not ignore unhealthful habits. © 2014 Lippincott Williams & Wilkins

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Table 2. Desired Support from Family Members Theme

Quotes

Healthful Eating Provide practical assistance

Older female 1: Like your parents and stuff . keeping healthy food in the house instead of like just quick snacks that will go Older female 2: And even if they did have like quick snacks, they could get like bananas and like fruit and good stuff that’s like good but also fills you up Older female: Healthy dinners. I always make my mom make healthy dinners Younger male: My parents don’t like, like when I’m wrestling, they don’t buy pop at all. They just buy water so there is no way I can eat an unhealthy product, which helps me a lot Older male: I had a friend who used to eat a lot of junk food .. He used to never buy lunch, but he would bring his own lunch and basically the same stuff in terms of calories. But his mother started making lots of sandwiches for him, so now he has really healthy sandwiches. So he has kind of changed his eating through support of his family

Motivate/encourage and recognize efforts

Young female: Yeah, like gratitude. It’s almost like, if you are doing really well, and you’re sticking to it then there’s always something they can do like, like a reward, like frozen yogurt or something healthy, delicious choice Older female: Like . if when I come home from school and I just sit down in front of the computer and start eating, my mom will sometimes say like “Hey, you probably shouldn’t be eating all that stuff.” And then like just remind me Younger male: Being positive instead of negative. Like saying, kind of what you said, like, “You can do it,” instead of like “You messed up once ..” Like something just to make you feel like you’re doing a good job

Avoid negativity or nagging

Moderator: What do they say that sounds naggy? Young female: They can repeatedly tell you something that you don’t necessarily want to do or are excited about doing. And they just can’t give it up once you have kind of decided no

Make similar changes/lead by example

Younger female: My mom and I have talked about trying to be healthier together, so like it’s almost like having someone there to support you and join you in that .. Older male: It’d also be helpful to have like a whole family like healthier eating habits because it seems like it’s me and just my mom that are trying to change our healthy eating habits, but my dad is still eating the same food Younger female: . it’s easier when someone (who) makes the food for you decides they are going to do this too. She also like buys the food so . it’s easier to keep . junk food out of the house Younger female: I think if they lead by example, too. To me it’s hard for them if they tell you and not do it themselves

Do not ignore unhealthful behavior

Moderator: What is the thing that parents and siblings do that is the least helpful? Older male: Not saying anything Older male: Like your parents see you just sitting like in the basement just like on the couch watching TV just eating all this junk food. If your parents walk down and see that or if they like join you, then you know it’s a bad thing because it’s not just you, it’s them, too

Physical activity Provide practical assistance

Younger male: Like setting up a schedule for you and like when you do, like go outside for like an hour then like work out for an hour and then like do homework and then do something physical after Older male: Sign you up for a workout membership. Help you do that Older female: Like my parents, we all have a trainer that comes to the house so that . like gets us all together to do stuff with the trainer

Motivate/encourage and recognize efforts

Younger male: Even if you are doing everything wrong, they could find one positive thing to motivate you (Table continues)

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Table 2.

Continued

Theme

Quotes Younger female: A lot of encouragement, ya know? . It’s easier if your parents are like ya know, nicely reminding you or saying good job after than if they are just completely being oblivious to it Younger female: There is kind of like a fine line when you’re a teenager because sometimes you are like really stubborn and stuff, so when your parents tell you to do something you are not always going to do it. So, if they are more relatable to you kind of, if they try to understand what your circumstances and then push you from there Younger male: Just don’t focus on such big things and everything little thing you do you get support for that it makes you feel better .. Like when I shoot hoops with my dad, if you had good form or something like that you just compliment on that, just the little things

Avoid negativity or nagging

Younger female: Yeah there is a difference between, ya know, like instructing you, like this mean old parent, and . like inviting you. You know? Saying “Hey, I’m going for a walk, you want to come with?” That’s a little bit easier than saying “You have to come for a walk” Older male: (in response to other participant comment, “You can’t play your X-Box if you don’t go outside”) I’d probably say threats would be the least helpful because it’s just going to make the teen more angry and more likely to rebel Older female: Not like nagging you to see if you did it, like exercised or anything like that, but actually have a conversation with you Older female: I know my parents, or more my dad, he like nags on me like, “Oh (name), you should really go exercise right now,” but like I have so much homework and other stuff that I need to get done. I’m like “Oh well, I’ll do it later,” and he’s like, “Oh you should do it now,” and we end up getting into this big argument. So maybe if they like kind of, like not tone it down where they don’t care, but just like down a little where you know they are like, “Hey you should do this,” “Oh, okay, maybe”

Make similar changes/lead by example

Younger female: I think the participation thing. Me and my mom can just, I don’t know, go for a walk every night or something Younger female: If your parents like encourage you to go for a walk, but then they just go sit down and watch TV, that’s kind of like . it doesn’t really make you feel like you really want to do that Older female: Or even if they (parents) would like work out with you, like it would be more motivation. Like if you were both at home, you could go do something together Younger male: I want them to support like what I believe in .. Like working out with me like once a week. They don’t have to do it like everyday, just helping

Do not ignore unhealthful behavior

Younger female: It would be unhelpful to not do anything about it, just be like “I don’t care, you can do whatever”

Physical Activity Similar themes emerged for parental support of physical activity. All groups agreed that parents provided motivation to be physically active when they encouraged adolescents to set their own goals, expressed confidence that adolescents could achieve goals, and provided recognition for adolescents’ efforts either verbally or with a reward. Conversely, participants noted diminished interest in exercise when they felt pressured by their parents to be active. Participants were particularly turned off by threat of punishment for not exercising and thought that parents could motivate more effectively through actions that respected teens’ autonomy such as conversation or invitation to join them for physical activity. Participants spoke of the importance of parent engagement in physical activity as an example and as Vol. 35, No. 8, October 2014

a means of supporting adolescents. As with healthful eating, several participants noted the detrimental effects of ignoring unhealthful behavior such as sedentary activity.

Friends and Other Peers Participants wanted peers, especially friends and teammates, to provide emotional support. Three themes were predominant for peer/friend support. Specifically, adolescents wanted peers and friends to motivate/encourage and recognize their efforts, make similar changes/do it together, and avoid negativity and teasing. Healthful Eating Across all groups, participants expressed that friends’ food choices have a strong influence on their own eating habits. Participants stated that eating healthfully is easier © 2014 Lippincott Williams & Wilkins

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Table 3. Desired Support from Friends and Other Peers Theme

Quotes

Healthful Eating Motivate/encourage and recognize efforts

Younger female: Well they just can say, like if you’re on a diet or you’re trying to get better habits or whatever, they can say you’re doing a great job and that they notice a difference, like say you’re not eating fatty foods so you have more of a positive attitude and more energy and stuff like that Younger female: I think like complimenting on their efforts, too, or something like that always helps Older male: Yeah, I could be like cruising around with my buddies, “Oh yeah, let’s grab some BK,” and they could be like “Nah, man, you’re about to gain like 3 pounds.” Be like “Oh.” Be like not eat BK

Make similar changes/do it together

Younger female: I used to be the only one who would bring a lunch and now like 5 of my other friends bring sack lunches Older female: (When asked what is not helpful): I have a friend that is obsessed with hot Cheetos and she’s kind of gotten me addicted, and she carries them around in a big bag in her backpack .. and like during classes she’ll be like, “Oh here, (Name),” and we’ll just like eat and take notes, and by the time we got like this much of the bag left like, so like having all that food that I love there Younger female: Well, at lunch a lot of my friends, well, the school lunches are really bad. But they get chips and a cookie every single day for lunch, and it really makes you feel like to fit in with them you would want to do that, but you don’t want to do that because it’s totally unhealthy Younger male: When friends are eating junk food, you want that instead of if you are eating something healthy. Then, it just kind of like, “Oh, I can go with that and be fine,” and each day it will build up more and more

Avoid negativity and teasing

Younger female: They can’t make fun of you. Teenage girls just like making fun of each other for everything, so like you can’t let them, like, well, they shouldn’t make fun of you for trying to be healthier Younger female: I think that when I was in elementary school, my friends would always tease me because my favorite thing in the world was spinach salad with hard boiled eggs on it. And I would have that a lot, but she would always like, I remember it was one day she just went on and on about how disgusting it was. So that doesn’t really, that definitely doesn’t make you feel good

Physical activity Motivate/encourage recognize efforts

Younger female: I think like complimenting on their efforts, too, or something like that always helps Younger female: Yeah, like the motivation thing. You might not want to do it, but if they push you to do it. Yeah Younger male: Compliments .. Like say, “Wow, you are looking good” Older male: Like the helpful comments, like if you say you start some weight loss program, like say, “Yeah, I can actually tell you are loosing weight or getting better endurance,” just basically any good comments that could help out

Make similar changes/do it together

Younger female: Join you when you decide to make a healthy choice. Or like just be more active, like I’ve been thinking about inviting all my friends to come hiking in my woods or go biking out there and stuff, and they’re a big part of your life, too, so might as well join you in that Younger female: Me and this really good friend of mine . we get so competitive with each other in a friendly way, and so a lot of times that like really helps push me. And I think she knows that the really competitive edge really kind of gets both of us going, so in a way that is kind of encouraging to me, but it’s just kind of friendly beating each other up, ya know? Younger male: Have my friends go play basketball with me because I know some of them are better than me, so they will motivate me to get better (Table continues)

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Table 3.

Continued

Theme

Quotes Older male: Like a good thing a person could do like if they were your true friend or something or they like care about what you are doing and trying to change, like if they see that you are making a big change, then maybe they would join, too, make you feel like you are helping more than one person

Avoid negativity and teasing

Younger male: That might affect you negatively too because if you feel you are being judged then you are not going to enter in and you are going to do less and less because you don’t want to feel that and that’s where the positive acceptance comes in Younger female: . if you’re planning on and you have all these athletic people and you’re not as skilled as them, you’re going to get a little teasing and stuff. Maybe it’s not like, sometimes it’s funny, but you can tell sometimes people get hurt by it and that is really going to draw them away from activities and all

when friends are eating well too. Participants felt supported when friends complimented behavioral or physical changes and showed interested in their progress. It was clear across groups that friends and other peers vary in their level of interest regarding healthful eating and their willingness to support a friend eating healthfully. All groups expressed concern about peer opinions and the potential to be teased or negatively judged by peers. Many participants described being selective about which peers they tell about their healthful eating efforts. Physical Activity Physical activity with friends had numerous benefits including making exercise fun, providing friendly competition, and offering new ideas for activities. Furthermore, exercising with friends reduced the likelihood friends would pressure adolescents to make less active choices. The amount of time spent in the company of friends made them logical exercise companions. For participants who played sports, teammates were natural sources of companionship and support. Participants frequently spoke of the importance of support from friends who were similarly committed to healthful habits, had similar ability levels, and who understood and cared about them. All groups expressed concern about teasing or negative evaluation during physical activity, especially when abilities are discrepant. All groups felt motivated to continue physical activity when peers complimented them or encouraged them to push harder.

Professionals Four themes predominated the area of professional support, namely, provide informed guidance, motivate/ encourage and recognize effort, build rapport, and follow/ encourage accountability. Participants viewed professionals as sources of informational support and wanted guidance from professionals perceived as knowledgeable. They viewed in-person professional contact as more trustworthy and personal than electronic/online contact. Participants desired professionals to build trust and get to know them so that advice could be personalized. As in Vol. 35, No. 8, October 2014

other relationships, participants appreciated when professionals complimented them on their efforts and progress. In contrast to parents, professionals such as trainers and coaches could push them, even put them down, without evoking rebellion. Primary care providers were generally not seen with enough frequency to build the personal connection necessary to receive nutrition or fitness motivation. Nonetheless, participants felt that primary care providers served an important role in providing feedback about overall health and providing referrals to other professionals, such as dietitians, who could offer more frequent and specialized support when indicated.

Enhancing Social Support Integrating Others into Appointments All groups felt it important to have individual time with professionals to get personalized support (Table 5). Despite this preference, some participants identified benefits of including a parent or friend in appointments, although such comments were rarely spontaneous. Potential benefits of including others in appointments included opportunities for partnership, accountability, and better understanding of one’s goals by significant others. There was not a clear sense of whether participants preferred parents, friends, or another type of person to be included; what was clear was that participants felt that only people who were committed to being supportive should be involved. Group-Based Interventions Group models for weight management or healthful lifestyles seemed a novel concept to participants. Sports teams or group fitness classes were more familiar. Whereas the idea of a healthful lifestyles “class” did not seem appealing, several participants mentioned that group options promoting physical activity are needed, particularly for those not in sports. Perceived benefits of groups included the structure of a schedule, accountability, exposure to a wider range of strategies, and shared purpose among group members. Many © 2014 Lippincott Williams & Wilkins

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Table 4. Desired Support from Professionals Theme Provide informed guidance

Quotes Young female: I think like tools, just like if they are just going to give you ideas, I don’t think it’s as helpful as if they actually set out a plan for you Older male: Tips kind of give structure to what you need to do. They could say, “You need to lose weight,” and then you are completely lost like, “How do I go about doing that?” But, if they give you tips, you can kind of structure your routine around those, and it’s easier to get started because you are not in the left wondering what to do Young male: I mean it has to be simple and easy, but it also has to be fact based .. If I can see that this is how it’s done or there is science behind it or this makes sense because of this and it’s simple or easy, then I’d be a lot more likely to do it than have to do all these different things Younger male: If I didn’t think they know what they are doing, I wouldn’t listen and I just wouldn’t

Motivate/encourage and recognize effort

Older female (speaking about trainers and coaches): . like if they give you compliments but also like maybe yell at you a little bit .. They have to push you, too Older female: . during the middle of the season, I kinda slacked off a little bit and my coach was like “Really?” You can do this, get off your ass and go.” And I was like “Alright, alright,” you know. So if you are kind of mean to me, that sounds a little messed up, but it’s true. If you’re someone like that. But if my friend were to say that to me, I’d be like “No, shut up and go away” or my mom Older male: Compliments like “you’re doing this pretty good” Older male: If the coach isn’t necessarily, you are not necessarily his favorite, but you see kind of more and more that he is paying more attention to you as you work harder at something, he probably doesn’t even have to say anything, but if you see that, that’s going to push you even harder because of the fact you know now that what you are doing is working and you’re not the only one who can see it

Build rapport

Younger male: I think you need a trust factor there too with doctors Younger male: The people you feel comfortable around or people you look up to have probably helped you the most Younger male: Well, if you didn’t know them, it’d be like, “You don’t know anything about me.” But if you knew them, I think it would (be helpful) because they have a lot of knowledge

Follow-up/encourage accountability

Older female: Well, you have someone you have to be accountable to Older female: . if they call you or you call them or visit, and like just make sure you keep on going Older male: If you are supposed to be working out and you’re not, and you get a call from your doctor saying, “Hey, have you been working out?” you’re like “uh, yeah” and then you go quick and do it Older female (speaking of visit to dietitian): Probably kept with us. Me and my mom, we both went and we just went one time. They never like checked up on us. Probably if they did that it would have been more helpful

participants expressed concerns that groups be tailored to individual ability, as it could be disheartening and make one vulnerable to teasing if the discrepancy among member skill levels were large. Participants held conflicting views as to participating with friends or unknown peers; whereas friends bring comfort and fun and could provide support out of group, unknown peers could offer new ideas, anonymity, and inspiration to impress. All participants were clear, however, that they prefer to be in groups with peers who have similar goals. Friends who were not serious about healthful changes could be a distraction. Electronic Communications Participants were less enthusiastic than expected about using the Internet and social media to enhance support for lifestyle change and voiced a number of concerns related to electronic communication and 502 Social Support and Adolescent Weight Management

information. Participants were generally skeptical of websites and apps run by unfamiliar people. They expressed a preference to receive guidance from someone who has known credentials or expertise. Furthermore, they felt that support such as compliments and encouragement would be more meaningful in person. Specific to communication with professionals, participants viewed regular communication as important and helpful for accountability. As noted above, participants valued face-to-face follow-up with professionals and viewed this contact as important for the relationship. Regarding out of appointment communication, participants felt that texts from professionals would be “weird” and that phone calls and e-mails were more appropriate. Social media was viewed as having benefits and drawbacks. Participants were more open to accessing Journal of Developmental & Behavioral Pediatrics

information shared by others (with caveats) than posting about themselves. Lifestyle change was viewed as personal, and the potential benefits of sharing this information widely was seen as not worth the risks. Positive aspects of social media included receiving motivation and inspiration from others, virtual peer pressure (i.e., being motivated to do something another has performed), and opportunities to get positive reinforcement from others when posting about one’s successes. Downsides of social media included opportunities for negative self-comparison and vulnerability to teasing, judgment, and criticism. Furthermore, social media was seen as impersonal, and even positive online support could feel disingenuous. Many participants felt an app to track food intake and physical activity would be helpful and a few mentioned having used one. Although such apps were viewed as useful, participants were wary of others accessing the information. Thus, tracking apps were not viewed as a means to enhance social support.

DISCUSSION It is well established that social support enhances the effectiveness of adult behavioral weight loss programs12 and that parent involvement is an important factor in weight management interventions for children.9,10,13,14 To the best of our knowledge, this is the first study assessing adolescents’ preferences for social support for weight management.

Sources and Types of Support As expected, participants most readily identified people from their everyday lives as desired supporters of healthful lifestyle changes, particularly parents and friends. The clinical implications of adolescents’ descriptions of desired support from family and peers include relevance for identifying vital components of existing interventions and aspects that need further development. The instrumental help adolescents desired from parents such as purchasing of healthful food and facilitating access to physical activities is consistent with stimulus control components of empirically supported treatments for children.16,31,32 Although adolescents’ descriptions of desired emotional support from parents had elements of positive reinforcement (e.g., praise and tangible rewards), the descriptions of emotional support were clearly unique to adolescence. Adolescents wanted emotional support through conversations and compliments rather than rules or mandates, reflecting a view of health behavior as personal choice and a desire for adults to respect their autonomy. Consequently, intervention components that could be effective for this age group include giving adolescents responsibility for goal-setting and self-monitoring and supporting families’ skill development in behavioral contracting and communication skills such as reflective listening (e.g., for parents to reinforce adolescents’ goal setting) and developmentally appropriate praise and reinforcement. Adolescents described their efforts being further facilitated when parents engaged in healthful habits Vol. 35, No. 8, October 2014

themselves. Whereas this theme overlaps in part with modeling components of family-based programs,31 this study illustrates what modeling means in the context of adolescent development. Adolescents did not speak of emulating their parents; rather, they described their parents’ engagement in healthful behaviors as making their parents’ support genuine (not hypocritical) and as increasing the likelihood that the home environment would be conducive to healthful habits. Somewhat surprisingly, some adolescents, particularly the younger ones, expressed interest in companionship support from parents. Even if they did not frequently join their parents for physical activity, several seemed to appreciate parents’ invitations to go for a walk, eat a healthful meal, or engage in some other healthful activity with them. Such invitations were at least preferable to being directed or advised. Strong evidence exists that peers, especially friends, influence children and adolescents’ eating and physical activity behavior, but the mechanisms of influence are less clear.33 This study sheds light on potential mechanisms. Participants described processes consistent with social facilitation theory, impression management models, and the normative model of eating,33 such as the effects of compliments versus negative evaluation from peers and a desire to impress peers during physical activity. Other described modes of influence are fitting with social cognitive theory concepts, such as friends motivating with compliments (rewards/incentive motivation), making exercise fun (increasing reinforcement value of activity), encouraging effort during physical activity (verbal persuasion to increase self-efficacy), easing the transition to new activities (facilitation), and making healthful eating easier by sharing a commitment to eating well (modeling and facilitation).3 Interestingly, adolescents across gender and age did not want support from just any friend; they valued support from people who were serious about supporting them and embraced a healthful lifestyle themselves. Adolescents across focus groups described numerous ways peers could derail their efforts, including friends who “tempt” them with junk food, social activities that distract them from working out, and the potential for negative comments and teasing from peers. These findings are consistent with normative models of eating and physical activity and previous research demonstrating positive effects of perceived support from peers above and beyond peers’ presence.33 Professional support was discussed in most depth when the facilitator specifically probed for the role of medical professionals and other non-family adults. Coaches and trainers were mentioned most spontaneously and with greatest elaboration. In contrast, adolescents viewed physicians as having too little contact or time for the follow-up needed to support behavior change. One implication of these results is that adolescents may be more likely to seek professional guidance for eating and physical activity through sports or gyms © 2014 Lippincott Williams & Wilkins

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than from professionals in medical centers. Thus, placing interventions in these contexts may make behavioral weight management programs more accessible to adolescents. Other aspects of discussion indicate the importance of regular follow-up, including face-to-face contact, for relationship-building and accountability. Particular to relationship-building, our findings suggest professionals would be wise to spend time probing for and listening to adolescents’ goals and motivators before providing advice or guidance, and to help adolescents develop a concrete plan of action, with an emphasis on options and choice.

Means of Enhancing Social Support in Interventions Findings emphasize the importance of giving adolescents time alone with professionals, consistent with previous work that found behavioral weight management intervention was most effective when adolescents and parents met separately compared with conjoint and adolescent-only conditions.34 Providing individual time for adolescents is fitting with participants’ views of health behavior change as a personal matter and might facilitate ownership of behavior change. Participants’ discussion around including others in individual or group interventions suggests potential for enhancing social support when done thoughtfully and with adolescent input. There was agreement among adolescents across groups that individuals vary in how supportive they are and that selected individuals, parents and friends alike, would need to “take it seriously” for their involvement to be of benefit. Adolescents’ expressed need for privacy suggests that it would be important to discuss with adolescents what information is shared with whom. Considering themes related to autonomy, designing interventions with greater expectations and opportunities for adolescentdriven decision making and action than is customary with family-focused interventions for younger children and structuring parent involvement to serve a more supportive than directive role are more fitting with adolescent development.35 Adolescents’ feelings about including friends and other peers in group interventions were mixed. Responses suggest that group composition needs to be carefully considered, especially in including individuals with similar levels of commitment and skill level. Furthermore, if friends are to be included, criteria for selection should include the ability to remain positively supportive of healthful behavior change. Participants’ views on electronic means of support were substantially less favorable than expected, although some of the skepticism may be attributable to the potentially high level of health literacy among this study’s participants (see Limitations). Whereas the Internet and social media can be a resource to get and share ideas such as recipes and exercise tips, there seems to be a fine line between helpful and toxic social media posts about individual health behavior. Participants’ mixed views regarding social media suggest that although others’ posts 504 Social Support and Adolescent Weight Management

about health behaviors or pictures of their bodies could be inspiring to a few, others find them annoying or disheartening. Similarly, as illustrated by participants’ references to “thinspiration,” social media has a potential for unhealthy messages.36 Furthermore, participants highlighted the potential dangers of posting about their health goals and behavior on social media such as vulnerability to teasing, a high cost given that many online venues were seen as too impersonal to facilitate meaningful support. Participants’ clear opposition to text messages from professionals contrasts with literature that identifies electronic communication, including the use of text messages, as a promising avenue for supporting health behavior change, at least with parents of children who are overweight.37 We do not believe our findings suggest that Internet, social media, and other electronic communications be abandoned as potentially helpful tools for enhancing promoting health behavior change among teens. Rather, participants’ comments point to a number of factors that need to be addressed when designing interventions with an online, electronic communication, or social media component: (1) make a face-to-face meeting the initial point of contact; (2) clearly identify expert(s) behind electronically provided information and make explicit their source of expertise; (3) offer opportunities for adolescents to communicate personally with an interventionist, preferably face-to-face, and allow opportunity for the adolescent to feel his/her goals are understood; (4) provide numerous ideas for healthful lifestyle change but tailor communication to individual goals; (5) give adolescents control over their privacy settings and who is in their social media network; (6) promote positive messages in social media venues and prevent opportunities for negative evaluation.

Limitations, Implications, and Future Directions This study’s findings should be considered in the context of its limitations. Readers should be aware of unique characteristics of our sample and exercise caution before generalizing findings to adolescents of diverse backgrounds. First, given the modest sample size, generalizability is potentially limited. Furthermore, although the racial, ethnic, and education background of our sample was representative of the surrounding community, the community from which participants were recruited is influenced by its proximity to a major medical center and the large percentage of county residents who work in health care, which could have impacted health literacy among our sample. Furthermore, this sample was comprised of largely white/European American adolescents with highly educated parents living in a small city or rural setting. Additional studies in communities whose economies are less dominated by health care and with samples of adolescents from diverse socioeconomic, racial, and ethnic backgrounds would lend perspective on the generalizability of our findings. As our study design had only 1 focus group representing each age 3 gender group, additional studies with larger Journal of Developmental & Behavioral Pediatrics

Table 5. Adolescents’ Perspectives on Means of Enhancing Support in Interventions Theme/Subtheme

Quotes

Including others in interventions Mind the drawbacks of including others in interventions

Younger male: If I were to go to a doctor, I would really just want to go by myself, not even my parents there because then it would be especially about you and you wouldn’t have any other distractions. Or like you wouldn’t have to think, “Okay, what does my mom think of me? Or what is my mom going to say?” You have that more honest response. I think that would also be beneficial to the doctors as well Older female 1: I just fell like it’s kind of like, when my parents are always watching me, it’s kind of awkward because then you feel like you’re not doing it to their standards. So then, I get really stressed out .. You’re like “I’m trying but you’re watching me, and it’s weird.” Older female 2: See, that would just piss me off. I would not be okay with that Younger female: Well, like some stuff you talk about with your doctor, you don’t want to talk about with other people. Like with eating habits it’s usually fine, but, if you could go to your appointment and talk to the doctor about how you’re happy or not happy with the way things are going and then, at the end, some supportive person could come in to review how things are going Older female: Yeah, I feel because my parents are really nosy anyway, so it would just give them like, even though it’s like going to help you, it would just give them one more thing to like get in my business about

Brief inclusion of parents and/or friends can help them understand and provide support

Younger male: Maybe a friend to the check up . and just to make sure that you’re doing it and sticking with it Older female: Maybe like the professional could give you a diet or give you an exercise program and just like have your parents know what it is, so they can help you keep on track Older female: I think it would be easier if you could have a friend be in there rather than have your parents are there .. It’s almost less awkward having like your friend there because maybe they could learn from it and be like, “Oh, hey, how are you doing? What are you doing?” and keep track that way Younger female: Yeah, I would say definitely have parents come to that, like the doctor’s visit so they know what you’re dealing with and so they can like help you along the way

Include people who are committed to supporting healthful habits

Younger female: Yeah, really supportive people because I know if you’re dad is not into it or he doesn’t . see no point in going, then it’s not going to help you at all Younger female: I think it depends on the friend, like because, again, it depends if they would want to join you and that working to eat healthier or be healthier and not like then I think that would be really nice to have like a buddy to do that with, but so it depends on the person Younger female: It would be good if they were coming to support you because you can always have more support, but if they are just coming along for the ride, it’s like you don’t need them there for that Older male: I would want people in my life included, if they share the same interests and share the same motivation

Group formats Fitness groups must be tailored to individual ability

Older male: Sometimes you are being pushed past your limit. Sometimes that’s good, but sometimes that’s bad because most of the time you are being pushed past your limit, and that is almost everyday of the week Older female: I find it intimidating to be with someone who is more athletic than you and more like has more activities like stuff than you .. I would rather be with someone who is on the same level as me than have a friend who is super sporty and stuff like take me under their wing Older female: So it’s like a little bit, not to be mean, but like if you’re planning on and you have all these athletic people and you’re not as skilled as them, you’re going to get a little teasing and stuff. Maybe it’s not like, sometimes its funny, but you can tell sometimes people get hurt by it and that is really going to draw them away from activities at all (Table continues)

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Table 5.

Continued

Theme/Subtheme

Quotes Older male: If you work out with people that can’t hold up to you, it’s just kind of a waste of time because if I were to be trying to be maxed out and I have this skinny kid trying to pull up this weight that I know he can’t pull up, I’m dropping this bar on the next notch down like by my neck

Group members should have the same level of motivation (regardless if they are friends or strangers)

Older girl: If everyone who actually wanted to be there, I think it would be different then if someone was like “Yeah, go do this”

Younger female: Make sure everyone is committed to it, so like they don’t like start eating really unhealthy and still come and to like kind of bring the team down in a way Older male: I would say the most important part is being there with you to do it, to keep you in it because if you are just alone in the group, sometimes you will just drop out of the group because you don’t feel involved. But if you have a friend there, then you both can stick, more likely to stay in the group Younger female: If you are trying to do it with your friend who doesn’t really want to do it, you know, this kind of person won’t like go home and sit on the couch and whatever, then I think it’d be easier to go with someone who you know is more has more the motivation who is going to motivate me than my friend who just slacks off Group formats could provide accountability and ideas

Older male: A healthy lifestyles group could be helpful because you have a group to go work out with and you have somebody. You can’t like skip out of it at least Older female: Just the being accountable. But then not if none of you did it, it wouldn’t be helpful. Everyone would blow it off and just hang out at the end of the group Younger female: Yeah, I think the individual attention is really good, but if you are in a small group, there would be more ideas for you to pick up. Like, oh she’s going to go on like a plan to eat like this many vegetables and fruits a day, then maybe I should try that, too Younger female: I think it would be really helpful because like relationships are a big part of life and just having that connection with people often can motivate you to do better things. And I guess, just having examples all around you, just having something set up weekly is really nice . (because) ou don’t have to worry about making the plans and telling yourself “Oh, you’re going to do this,” but actually knowing “Oh, you’re going to do this”

Use of technology for communication Technology cannot replace humans

Older male: It would be easier to lie if you were doing over text or phone call then face-to-face Older male: I don’t think the Internet will be giving you compliments or anything Older male: I mean I would trust a person more than I would trust a computer telling me what I’m doing wrong because it’s like maybe the person went through the same thing, so they probably know more about it Moderator: Would you want (check ins) to be kind of mass things that they send to everyone or personal? Multiple younger females: Personal. Younger female: Because if you go in and you talk about something specific, then you’re going to want something personal

Texts from professionals are “weird;” phone calls and e-mails are appropriate

Younger male: Like they call you and they set a time and they’re using their time to call you and see how you’re doing and it makes you feel important Older female: Like if they call you or you call them or visit and like just make sure you keep on going Older female: I know I am on the computer a lot .. And like I am always like if it’s important then I will either text or like e-mail. So, texting would be a little weird, but like e-mailing back and forth, “Hey, just remember to do this” or “Have you been doing this?” or whatever, might be easier Younger female: Texting from the doctor is like a different form of nagging (Table continues)

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Table 5.

Continued

Theme/Subtheme

Quotes

Social media benefits Motivation and inspiration

Older female: If you have someone (as a friend on social media) that is your inspiration for what you want to look like or how healthy you want to be, or if they do the same stuff you want to do, that would be inspiration or motivation to work out Younger male: I remember right before I started, I saw on (TV channel) there was this blind triathlon guy in this area. He, I said, “If a blind guy can run a triathlon, swim, and bike and do all this, then why can’t I? I should be able to do that, and I’m not blind. There was nothing holding me back Younger female: Well, maybe someone at (medical center) could post like a teenage daily challenge, like “Walk a mile today” or “Eat an orange today” or something simple like that Older male: I feel like seeing that (Facebook Beautiful Teen Contest) could make you want to strive to have a 6 pack

Positive reinforcement

Younger male: Well, if you would be like “Oh, I lost 3 pounds this last week,” people would probably be like “Oh, nice job” and that would be positive motivation Older female 1: So, yeah, the privacy aspect, but if you reach a goal. Older female 2: Yeah, you can share it .. Have that positive community, like “Oh, congratulations,” being really positive about it

Information

Younger female: I follow this person on Twitter . they have healthy exercising stuff and links to websites where you can find different recipes for healthy foods, and I’ve actually found that really helpful because I’ll be scrolling through the timeline and they pop up and I’m like “oh, I guess I should go do something” Older female: Also, like if you were just bored to look on Pinterest like you have like those work out things so it’s helpful

Virtual peer pressure

Older female 1: I saw this girl post a status like “working out for .” or “not working for 1 day makes me feel gross.” And I was like “Yeah, I should probably work on that.” Older female 2: Kind of annoying but it’s kind of like, I should probably get on that Younger male: Well, it could show there are a lot of other people going through the exact same things trying to get through it Older female: Well, if you just like saw things on your Facebook feed about like eating healthy it’s just like an extra reminder in your day to do that

Social media drawbacks Negative self-comparison

Older male: I’ve seen on Facebook .. It’s all these guys or girls with their shirt off or something, and they are all 6 pack and lean and just kind of makes you a little bit self conscious Older female: It almost makes you feel like “Oh well, I didn’t do that.” And . it makes you feel kind of like insecure that they are doing so great and you’re not Younger female: Well, technology it can be helpful like that, but sometimes when you hear about these super like perfect people and stuff, and that can kind of bring you down too

Vulnerability to teasing, judgment, and criticism

Older male: . once you put it out there, it’s out there. It could spread and make you look like an idiot Older male: Yeah, it would be unhelpful because they would probably say bad things, they would downtalk you

Impersonal

Older male: I feel like that Facebook and texting and everything is so impersonal that it’s not even going to make a difference Younger male: I don’t think you really need to share it with everyone you know and just share it with friends and family Younger male: Like on Facebook, too, not all of your friends are your close friends or friends in general, they are acquaintances

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sample sizes are needed to investigate gender and age trends within adolescence. Finally, further investigation could explore potential differences in the support desired by treatment-seeking adolescents versus those who have not sought treatment for overweight or obesity. The use of qualitative methods to solicit adolescents’ thoughts about social support for healthy lifestyle change resulted in rich information with implications for health promotion interventions for adolescents. The unique characteristics of this stage of development limit the transferability of empirically established child- and adult-focused interventions to adolescents. Findings suggest that although the broader theoretical concepts from established treatments apply to adolescents (e.g., concepts of modeling, stimulus control, and positive reinforcement from behavioral and social learning theories), these concepts may need to be applied differently with careful consideration of adolescent development, especially in respecting and promoting adolescent autonomy. Throughout our discussion, we have highlighted treatment implications from a developmental standpoint. Our findings also have measurement implications. Although measures of social support for healthful eating and physical activity exist,20,38 to the best of our knowledge none were developed with adolescent input. Use of these findings to develop a measure social support could lead to an instrument with strong content validity. In summary, this study provides rich information about how family, peers, and professionals could best support adolescents’ efforts toward a healthful lifestyle. Our findings underscore the influence of parents and peers on adolescents’ healthful eating and physical activity and provide insight into making weight management interventions relevant to this developmental period. REFERENCES 1. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA. 2010;303:242–249. 2. Patton GC, Coffey C, Carlin JB, et al. Overweight and obesity between adolescence and young adulthood: a 10-year prospective cohort study. J Adolesc Health. 2011;48:275–280. 3. McAlister AL, Perry CL, Parcel GS. How individuals, environments, and health behaviors interact: social cognitive theory. In: Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008:169–185. 4. Reilly JJ, Kelly J. Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. Int J Obes (Lond). 2011;35:891–898. 5. Hwang KO, Ottenbacher AJ, Lucke JF, et al. Measuring social support for weight loss in an internet weight loss community. J Health Commun. 2011;16:198–211. 6. Hwang KO, Ottenbacher AJ, Green AP, et al. Social support in an Internet weight loss community. Int J Med Inform. 2010;79:5–13. 7. Kirk S, Zeller M, Claytor R, et al. The relationship of health outcomes to improvement in BMI in children and adolescents. Obes Res. 2005;13:876–882. 8. Robertson W, Thorogood M, Inglis N, et al. Two-year follow-up of the “Families for Health” programme for the treatment of childhood obesity. Child Care Health Dev. 2012;38:229–236.

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