This chapter will address the following American College of Graduate Medical Education competencies: patient care, medical knowledge, and interpersonal and communication skills.

Patient Care: This chapter will enable pediatric health care providers to help families understand the special developmental tasks of adolescents around healthy lifestyle change and the balance of independence and family support needed in order to achieve positive lifestyle change.

Medical Knowledge: Understanding how psychosocial and behavioral factors influencing disease development and maintenance pertain to adolescent overweight and obesity will enable pediatric health care providers to apply this knowledge to patient care and research in order to deliver competent services for their adolescent patients and their families.

Interpersonal and Communication Skills: This chapter will help the pediatric health care provider communicate more effectively with their adolescent patients and families in order to achieve compassionate and effective care.

As youth develop throughout adolescence, parents and other caregivers are positioned to play an ongoing role in the prevention of excess weight gain. Even with adolescent developmental shifts to greater autonomy and peer involvement, caregivers remain an important influence during this time because they are integrally involved in household food selection and can serve as critical models of healthy lifestyle behaviors.¹ Researchers have linked higher engagement in adolescents’ health promoting behaviors over time to family behaviors such as greater frequency of family meals, caregiver facilitation of physical activity, and less parental talk about weight.² Working with caregivers of adolescents to provide a healthy environment and otherwise promote healthy lifestyle behaviors is an important component of fostering healthy weight for youth.

Despite the apparent potential for caregivers to play a role in this arena, there is little research on caregiver components of adolescent overweight and obesity prevention. To date, the majority of obesity prevention programs have been school-based interventions that do not take into account broader environmental factors such as family context.³ There are a few studies that suggest that interventions which target parenting practices hold more promise than interventions with children only or those only providing nutrition and exercise education but no parenting strategies for caregivers.⁴ These studies have focused mainly on school-aged children rather than adolescents, but the same is likely true for older youth. In one study of middle and high school students, there were higher rates of obesity for adolescents with less parental control over their physical activity and eating habits,⁵ suggesting that parents do have significant influence over these lifestyle behaviors.

This chapter aims to provide pediatric residents and other health care providers with a better understanding of how they can work with caregivers of adolescent patients—and patients themselves—to promote healthy weight in primary care or Stage 1 and 2 treatment settings. (For a description of the staged approach to pediatric obesity treatment, see Chapter 12 of this book.)

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  First, health care providers should conduct a behavioral and family systems assessment in clinic to determine family functioning as it applies to lifestyle behaviors.

  
  
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  Second, it is also important for providers to counsel families regarding lifestyle factors to promote healthy weight.

  
  
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  The third practice principle is to empower caregivers to parent authoritatively without using food and screen rewards or restricting physical activity.

  
  
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  In keeping with developmental tasks of adolescents, a fourth role for providers is to promote increasing adolescent autonomy for healthy lifestyle choices in conjunction with ongoing caregiver involvement.

  
  
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  Last, it is important for health care providers to give caregivers guidance in ways to promote healthy body image in their adolescents.

In order to develop individualized, family-centered interventions, the pediatric health care provider must first have a thorough understanding of what characterizes the family life of the adolescent. Although there are no guidelines for such assessment for Stage 1 and 2 interventions, there is expert consensus regarding family assessment in tertiary care that is applicable for prevention and early intervention. Pediatric psychologists specializing in weight management have recommended conducting a thorough assessment of the family environment including family composition (with extended family and those particularly involved in meals), family stressors, behavior management strategies, parenting styles of all caregivers, parent-adolescent communication and boundary issues, quality of family relationships, financial history, and food insecurity.⁶ Table 10-1 lists potential questions to gather information about these areas. A better understanding of the family environment, parenting practices, and cultural beliefs will allow for optimal tailoring of interventions and will aid in determining whether a family is likely to be able to implement recommendations addressed in the ensuing practice principles on their own or if they will need referral to a pediatric psychologist or other child behavioral health specialist.

Similar to the recommendations for younger children, pediatric obesity experts recommend that all adolescents within the 5th to 99th percentile for body mass index (BMI) receive education during primary care visits about nutrition, physical activity, and screen time using evidence-based obesity prevention strategies.⁷ The importance of this recommendation is underscored by research showing that adolescents report low levels of healthful eating and exercise regardless of their weight status.⁸ Obesity prevention and Stage 1 obesity treatment (Prevention Plus) strategies include increased consumption of fruits and vegetables (at least 5 servings per day), decreased screen time (less than 2 hours per day for adolescents and no television in bedrooms), fewer sugar-sweetened beverages (none or almost none), increased physical activity (at least 60 minutes per day), a family approach to behavior change, more frequent family meals, fewer meals away from home, breakfast daily, and at least 3 meals a day.⁷ Sleep hygiene is also important for healthy weight promotion; dysregulated sleep has been associated with higher BMI.⁹

Stage 2 intervention (structured weight management) builds upon Stage 1 with the recommendation that nutrition education be provided by a registered dietitian or a physician or nurse practitioner with additional training in nutrition. For adolescents and their caregivers, addressing skipping breakfast and eating family meals¹¹ could be particular areas of emphasis for intervention. Practitioners in Stage 2 settings should also assess for unhealthy eating behaviors that can contribute to obesity in adolescents, including dieting, boredom eating, emotional eating, binge eating, and nighttime eating.^{12, 13, 14, 15, 16} Furthermore, interventions that focus on enhancing organization and overall time management are likely to improve implementation of other recommendations and could be an important component of Stage 2 interventions if caregivers and adolescents have been unsuccessful with implementing recommendations in Stage 1.

Given adolescents’ affinity for technology (eg, Internet, texting, social media, smart phone applications) and their amenability to the use of technology in behavioral intervention,^17,18 technological tools may be helpful for promoting and tracking change.

Weight bias

When delivering lifestyle counseling, being mindful of weight-bias and approaching caregivers in a nonjudgmental and nonblaming manner is important.¹⁹ Normalizing the occurrence of poor nutrition and tendencies toward sedentary behavior in adolescence and empathizing with the caregivers about how difficult it is to foster behavior change in teenage children can allow health care providers and parents to collaborate more effectively. Motivational interviewing for pediatric obesity, as described by Resnicow and his colleagues²⁰ and reviewed in Chapter 15 of this book, can be a useful approach to promote healthy lifestyle behavior change.