A Qualitative Study of Successful Adolescent and Young Adult Weight Losers: Implications for Weight Control Intervention

Abstract

Background:

Our study aims to provide an in-depth analysis of behavioral strategies, psychological factors, and social contributors to adolescent weight loss and weight loss maintenance among participants in the Adolescent Weight Control Registry (AWCR).

Methods:

Qualitative analyses were conducted using semi-structured interview data from 40 participants from the AWCR who successfully lost ≥10 lbs and maintained their weight loss for at least one year.

Results:

In contrast to existing literature, our findings suggest that primary motivating factors for adolescent weight loss may be intrinsic (e.g., desire for better health, desire to improve self-worth) rather than extrinsic. In addition, life transitions (e.g., transition to high school) were identified as substantial motivators for weight-related behavior change. Peer and parental encouragement and instrumental support were widely endorsed as central to success. The most commonly endorsed weight loss maintenance strategies included attending to dietary intake and physical activity levels, and making self-corrections when necessary.

Conclusions:

Results from this study highlight considerations for future adolescent weight control treatment development.

Introduction

More than 30% of US adolescents are currently overweight or obese.¹ Pediatric overweight and obesity are associated with numerous negative physical and mental health outcomes, including high blood pressure, heart disease, and negative psychosocial consequences.^2,3 Given that adolescents who remain overweight are at overwhelming risk for adult obesity⁴ and that teens become increasingly responsible for their own health behavior choices,⁵ the adolescent transition represents a critical period for the prevention of obesity in adulthood.⁶ Notably, few studies have evaluated the effectiveness of weight control interventions for adolescents.⁷ Moreover, adolescent weight loss interventions have demonstrated considerable variability in treatment outcomes.⁸ Potential explanations for these inconsistent weight loss outcomes have yet to be thoroughly explored. Identifying the factors most salient to adolescents' successful weight loss and maintenance is an important step to increasing the efficacy of extant adolescent weight control interventions.

There are unique challenges associated with weight loss during adolescence that current interventions may not adequately address. Despite the developmental task of autonomy⁹ and adolescents' increased reliance on peers as social referents,^10,11 adolescents continue to rely on parents for instrumental and emotional support.¹² Previous research has shown that adolescents who have successfully lost weight have parents who engage in weight loss behaviors, including self-monitoring, altering high-fat food availability, and employing personal trainers.^13,14 Adolescents consistently report that emotional and instrumental support from parents is central to weight control, especially in underserved populations.^15–17

To date, only three studies have explicitly focused on behaviors of adolescents who are successful with weight loss. Findings demonstrate that, as compared to their unsuccessful peers, successful weight losers are more likely to decrease consumption of sugar-sweetened beverages, decrease sedentary activity, increase participation in physical activity (PA), and increase their commitment to adhere to these healthy behaviors.^18–20 Though these studies provide preliminary information regarding behaviors of successful adolescent weight losers, they do not describe antecedents and motivators for weight loss.

One avenue for gaining further insight into the experiences of adolescent weight losers is qualitative research. Qualitative research has potential to elucidate motivations, values, and experiences of individuals, which may inform intervention design and implementation.²¹ In the adult literature, combining data from successful weight losers' behavioral indicators (e.g., better nutrition, increased PA, and self-monitoring) and internal processes (e.g., dietary restraint, desire for a better appearance, and motivation) provides valuable information regarding motivators for adult weight loss.^22–25 Information gathered from these qualitative studies was novel and has contributed to more-effective behavioral weight interventions for adults. However, the extent to which these findings are consistent with weight loss experiences of adolescents is not clear. To date, only one study has qualitatively explored successful weight loss in adolescents. Gierut and colleagues²⁰ found that adolescents who successfully lost weight were more likely to adhere to the healthy obsession model, a model that posits a preoccupation with strict adherence to behaviors such as controlled eating and self-monitoring as critical components to weight control. However, this study examined the experiences of only four successful weight losers, which limits the generalizability of this study's findings.

Our study aims to provide an in-depth analysis of behavioral strategies, psychological factors, and social contributors to adolescent weight loss and maintenance among participants in the Adolescent Weight Control Registry (AWCR). Specifically, we conducted qualitative analyses to achieve the following research aims:

1. Describe the unique influences of peers, parents, and family members on achievement of weight control success among adolescents.

2. Explore motivations for behavior change that are consistent among successful adolescent weight losers.

3. Understand whether behavioral weight loss strategies used by adolescents are consistent with those reported by adults.

4. Develop specific recommendations for intervention development that may alter clinical care for adolescent weight loss.

Methods

Participants

The study sample included 40 adolescents enrolled in the AWCR, a national observational survey of long-term maintenance of weight loss among adolescents. Participants were recruited using social media, fliers posted in community locations, and through national and local media coverage of the AWCR. Inclusion criteria were that participants (1) be 14–20 years of age, (2) have met criteria for overweight or obesity during adolescence, and (3) have achieved and maintained a weight loss of ≥10 lbs for at least 1 year. Adolescents were excluded if their (1) current BMI<5th percentile for their age and sex or (2) highest weight did not meet criteria for overweight (≥85th BMI percentile for ages 14–17 or BMI≥25 for ages 18–20).

Procedures

After initiating contact with study staff to determine eligibility, informed consent documents were mailed to participants. Parental consent and adolescent assent were obtained for participant's <18 years; individuals 18 and older provided their own consent to participate. Though participation included both quantitative (i.e., questionnaires) and qualitative (i.e., 30-minute self-structured interview) components, only qualitative data are presented in the current study. Participants received a nominal payment in the form of a check or gift card upon completion of the study. All study procedures were approved by institutional review boards at the authors' institutions.

Measures

Demographic information and weight history

Demographic information was self-reported by adolescents. Adolescents reported their weight history, including current weight and height, lifetime maximum weight, and duration of weight loss maintenance. Previous research suggests that adolescent's self-reported weight is sufficiently reliable and valid.²⁶ BMI before and after weight loss was computed using both current and maximum body weight according to the formula provided by the CDC.²⁷ Duration of the criterion weight loss (≥10 lbs) was computed by subtracting 10 lbs from maximum lifetime weight and calculating the number of months participants remained at or below this reduced weight.

Semistructured interviews

Interview questions were developed using a two-phase process. During the first stage, three researchers with expertise in behavioral weight control generated a series of global content domains considered relevant to teen weight loss. In the second phase, an independent set of experts with knowledge of both weight control and qualitative methodology refined the domains and generated a series of open-ended questions. Interview questions covered motivations for weight loss, role of parents and peers in facilitating or impeding weight loss, and behavioral strategies used to promote weight loss. All interviews were transcribed by a research assistant who did not conduct interviews. Two independent reviewers checked the transcripts for consistency with audio recordings. Questions comprising participant interviews are detailed in Table 1.

Table 1.

Participant Interview Questions

Theme	Initial question	Example follow-up questions
Weight loss story	“Tell me the story of how you lost weight.”	“What got you started?” “Was there a trigger for your weight loss efforts?” “Whose decision was it for you to lose weight?”
Changes in behavior and/or environment	“What did you do to help yourself lose weight?”	“What changes did you make?” “Did you make any specific changes to your diet or exercise habits?” “Did you make any specific changes to your home environment?”
Role of the family	“How has your family influenced your weight loss efforts?”	“What role did your parents play in your losing weight?” “How were your exercise and eating habits similar or different from your parents?” “Were your brothers/sisters involved in helping you lose weight?”
Role of friends	“How have your friends influenced your weight loss efforts?”	“What role did your friends play in your losing weight?” “What things did your friends do that were helpful to you when you were trying to lose weight?” “How involved were your friends in your weight loss efforts?”
Keeping the weight off	“What kinds of things have you done to maintain your weight loss?”	“How hard has it been for you to keep the weight off after losing it?” “What are the hardest situations for maintaining your weight?” “What role have family and friends played in helping (or hampering) your efforts to keep the weight off?”
Previous weight loss attempts	“Did you try to lose weight before?”	“What got in your way when you tried to lose weight before?” “What made this time different?”
Suggestions for intervention development	“What would you say to help other teens who want to lose weight?”	“If we started a program to help teens lose weight, what are the things we should include based on your experiences?”

Statistical Analyses

Interview data were analyzed using an integrative qualitative research methodology, which combines inductive and deductive organization. Following procedures outlined by Creswell,²⁸ two coders read the interview transcripts to identify “expected” (i.e., hypothesized themes generated using previous research [deductive method]) and “emergent” (i.e., themes arising from data analysis [inductive method]) themes related to adolescents' perceptions of factors contributing to their weight loss success. All interview transcripts were double coded by two independent raters using NVivo 8, a commonly used qualitative data analysis software. The two raters coded 91.28% of interview content reliably (i.e., arrived at the same coding decision). All coding discrepancies were then discussed with the first author and resolved through consensus. Analogous responses were examined for similarity, and if it was determined that the responses were conceptually similar, the statements were coded under the same theme. Responses were allowed to be coded under multiple categories. Saturation for each category was established to ensure adequate attention to all interview responses.

Results

Demographic characteristics and weight loss summary data are provided in Table 2. Adolescents' weight loss motivations and strategies to lose weight fell into four overarching themes. Themes and sample quotations are included in Table 3.

Table 2.

Demographic and Anthropometric Characteristics of Study Participants^a

Characteristic	N	%
Age, years
15–16	8	20
17–18	17	42.5
19–20	15	37.5
Sex
Female	32	80
Male	8	20
Educational attainment
Junior high school (7–9 total years)	4	10
High school (10–12 total years)	11	27.5
Some college (less than 4 years)	25	62.5
Race/ethnicity
White	33	82.5
Hispanic/Latino	2	5
Black	1	2.5
Asian	1	2.5
Other	3	7.5
Amount of weight lost, lbs
10–20	10	25
21–30	12	30
31–40	9	22.5
41 or more	9	22.5

	Mean	Standard deviation
Highest % overweight	53.19	31.28
Current % overweight (N=32)	15.24	18.81
% overweight change (N=32)	−45.17	27.84
Highest BMI	30.74	5.64
Current BMI	24.08	3.53
BMI change	–6.66	4.70

Three participants did not provide descriptions of parental weight. Eight participants' current ages exceeded the upper age limit of the CDC growth chart for percent overweight.

N=40.

Table 3.

Themes Endorsed by Study Participants^a with Sample Quotations

Behaviors (N; N female)	Quotations
Altering food environment (23; 20)	“I really started buying foods that were healthier…I also stopped going to McDonalds.”
Changes in diet (40; 32)	“I ate more fruits and vegetables; I tried to cut out a lot of cheese and butter, sugar, stuff like that.”
Increase in physical activity (39; 31)	“I have never been good at being physically active, I am not very coordinated. But I decided that I really just wanted to, I made a goal for myself, 10 minutes a day. I started out walking around my neighborhood for 20 minutes every night. Then I started to jog, and then I started to run.”
Outside support (25; 20)	“[It would be helpful] if you could find a [weight loss program] because the people who were doing it were really nice and they taught me a lot. And also, there was a group of kids so you could find people who wanted to do the same thing as you, like lose the weight and keep it off. It is really good because you know what everyone else is going through.”
Portion control (22; 19)	“As of now, I'll still have ice cream, cake, brownies. I just have smaller portions of it and only eat it every once and a while and I feel fine.”
Reducing sweets (25; 22)	“I stopped eating junk food, chips, or things like that. If I was hungry I would snack on more fruit and things like that. I just tried to substitute it, made wiser choices.”
Self-monitoring (20; 18)	“We did weight watchers but we didn't sign up for the meetings or anything, we just kind of counted points ourselves and stuff.”
Consistent physical activity (31; 24)	“I still go running at least three times a week.”
Course corrections (23; 20)	“You're going to have a bad day or a bad week or say you even go off for a whole month, you know. But that doesn't mean you stop. You just get back on the next day. And you keep trying until it becomes more of a habit…You just always need to remind yourself that tomorrow's another day.”
Maintaining diet plan (35; 29)	“When you make changes, you have a whole change of heart. I changed my diet forever. Dieting—it's not like, for 6 months I'm going to eat really well and then it'll just stay off for the rest of my life…I've learned that you always have to control the portions you have to always pay attention to what you're eating.”
Monitoring weight (7; 5)	“If I weigh myself everyday, then it is a little discouraging because, you know, [your weight] fluctuates.”
Motivators (N; N female)
Appearance (23; 19)	“And then also being in PE and having to go in the locker room and change and I noticed that I wasn't as fit as the other boys, and I didn't like that either…So in a way I was embarrassed and intimidated.”
Desire for better health (25; 20)	“I knew I wasn't healthy, and I went to the doctor and the doctor kind of said you are heading towards diabetes, so it made me want to change my health.”
Doing things you enjoy (20; 17)	“Just finding something to do that is active. So maybe don't enjoy running, that is totally fine, just find something else that you enjoy doing, and then it is not like a chore or something that you have to…it is not exercise when it becomes an activity.”
Major life transition (15; 13)	“Part of the thing too is I grew up in California and my family and I moved to Colorado when I was fourteen. So Colorado has a really healthy mindset. It's much more outdoors and active, so I think that helped.”
Peer acceptance (17; 13)	“As a teenager and as a girl you want to have good self-esteem and you want to feel equivalent to your peers. And I have always been friends with girls who were super thin. So for me it was a motivation to fit in, to feel that way.”
Self-motivation (38; 30)	“It helped when my parents didn't pressure—I have to want it in order for it to happen.”
Self-worth (27; 22)	“I just really didn't feel good about myself. “
Family and peer factors (N; N female)
Family joined in goals (39; 31)	“They were a support system…it was a really good thing for our family. We grew closer together. It helped a lot. Each of us was able to compare strategies and brag about the goals that we met, and it was great.”
Helpful home environment (28; 23)	“If junk food is everywhere around you, it's so much harder. If the parents would just get rid of that stuff originally…that would automatically bolster up their chances to lose weight.”
Joining physical activity (35; 28)	“We did family 5ks and we started getting more active as a family and my parents started triathlons and half marathons. It was a positive influence to be more active.”
Parental changes to home environment (32; 24)	“My mom was like a great cook and she would always do pastas and a lot of mashed potatoes and a lot of starch. I made her aware that I wanted to lose weight and be more healthy and so she changed things in her meals. She added more greens to the table and more fruits and we went from drinking crystal light to water, just water.”
Peers and family noticed positive change (24; 21)	“It's just nice to hear ‘Oh, you lost weight.’ It's just really encouraging to know other people notice that.”
Peers joined in goals (21; 17)	“Me and my friends were just a little more active with each other, rather than just sitting around doing whatever we would actually go outside and start moving.”
Peers provided motivational support (28; 23)	“I guess, well, when I went back to school my senior year they were more supportive of me and they would ask me, ‘How did you do it?’ ‘Give me your secrets or tricks!’ I would say, ‘Well there wasn't any secrets or tricks I did, it was just being healthy.’ They kind of looked up to me, if that makes sense.
Difficulties in maintaining weight (N; N female)
Negative family influences (25; 21)	“You can encourage them to do things, but if you make them do it, then they're not going to want to do it for themselves—so it won't work.”
Negative peer influences (24; 20)	“Well my friends that weren't very health-conscious, they just… tell me that I should just come with them to McDonalds or something like that, cause they didn't personally understand what it's like to have to worry about physical attributes and stuff.”
Unhealthy home environment (26; 20)	“In terms of changing my environment, it was something that I couldn't change the feelings of my family. I couldn't change the fact that my brother is going to want Domino's pizza every Friday night, but what I can change is myself, my interaction with the situation, and that's what I did, I just walked away from it.”

N=40; N female=32.

PE, physical education.

Theme I: Behavioral Factors

Successful adolescent weight losers increased their PA, made dietary changes, and used outside support systems to facilitate weight loss. Moreover, participants endorsed realizing the importance of maintaining these lifestyle changes in order to maintain their weight loss.

Dietary changes included reducing consumption of unhealthy foods, controlling food portions, and eating preferred foods in moderation. Approximately half of all participants (n=23; 57.5%) reported that they often made healthier food choices in an effort to lose weight/maintain their weight loss by bringing their lunch to school, limiting their fast food intake, choosing healthier alternatives at fast food restaurants, and buying healthier versions of the foods that they liked. Most participants (n=35; 87.5%) realized that they could not completely eliminate unhealthy foods. One participant said:

“I tried to cut out all the snack food and junk food like that. You can cut if off for a while and then you just end up binging…As of now, I'll still have ice cream, cake, brownies. I just have smaller portions of it and only eat it every once and a while.”

Participants overwhelmingly increased their PA in a variety of ways, including structured activities such as school sports, dance classes, and aerobic fitness classes, as well as choosing to walk instead of to drive as a method of transportation, or to participate in community running races (n=39; 97.5%). When asked what advice they would give to other teens looking to increase their PA level, participants mentioned that it is important to “do something you love to do, don't force yourself” and “track your progress.” They also identified that “baby steps are important in exercise.”

Outside support of teens' dietary and PA changes included Weight Watchers, nutrition classes, online support groups (e.g., an online social media challenge), support from a doctor or a nutritionist, or a school- or community-sponsored program (e.g., school-based “Biggest Loser” challenge) (n=25; 62.5%). These programs provided both social support and education related to weight loss. For example, teens received nutrition and exercise information, were taught principles of self-monitoring and accountability, and learned to address emotional challenges. Further, these supports also often provided teens' parents education on topics related to their teen's weight loss.

Teens realized the importance of continuing their new diet and exercise behaviors in order to maintain their weight loss. Teens cited consistent PA (n=31; 77.5%), maintaining their diet plan (n=35; 87.5%), and making consistent course corrections (n=23; 57.5%) as critical to their weight loss maintenance. One teen said:

“It's a slow and steady [process], [you've] got to give yourself some leeway. You're going to have bad days and you just can't let those bad days get you off course. You just got to get back on.”

Theme II: Motivation

Participants primarily cited internal motivation, self-worth, and a desire for better health as motivators for their weight loss. The majority of teens emphasized that it was their decision to lose weight and that this decision helped them resist unhealthy foods or exercising regularly (n=38; 95%), and that life transitions often spurred these changes. Adolescents also reported that success served as motivation to continue healthy lifestyle behavior changes.

Adolescents wanted to set realistic goals, accept themselves for who they were, and keep a positive mindset as they worked toward improving their self-worth through weight loss (n=27; 67.5%). One teen said, “I just wanted to see myself as beautiful, to not just look in the mirror and think I look decent today. I wanted my own self-worth. I wanted not just myself to see it, but others to see it too.” Other comments included, “I didn't want to be the fat guy”; “I got sick of who I was seeing in the mirror”; and “I didn't feel confident.”

Many adolescents (n=25; 62.5%) went on to say they were motivated to exercise to become healthy, as opposed to targeting a specific body shape or size. Participants described wanting a different life for themselves, compared to family members who were obese. They did not want to develop chronic diseases, such as diabetes or a heart disease:

“I realized that I wasn't changing my body, I was changing my life. And I was in essence saving my life, because I had grown up seeing my family, all of my family, every single member of my family is morbidly obese…They have diabetes and heart disease and there have been so many issues…I always have felt like I've been missing out and my family has been missing out on life in general. So I realized a few years back that I needed to change my life and to save my life and to live life.”

Finally, major life transitions were identified as a motivating factor of weight loss (n=15; 37.5%). Participants indicated that school transitions (e.g., high school to college) prompted weight changes because they wanted to excel at sports and be accepted by their peers. Some participants reported that moving to a different state or country facilitated weight loss because of cultural or environmental characteristics of the new residence (e.g., biking instead of driving and adopting new dietary patterns). Starting a new job encouraged weight loss because the need to be physically healthy for optimal job performance highlighted the importance of health behaviors. In addition, jobs facilitated weight loss by reducing the amount of time adolescents engaged in sedentary activities.

Theme III: Positive Environmental/Social Factors

Environmental factors that contributed to teen weight loss success included family involvement with setting goals, parents making changes to the home environment, family support of PA, peers and family noticing positive change, and peers providing motivational support.

Parents actively participated in adolescents' weight loss goals by modeling healthy eating and exercise behaviors and encouraging their teens' behavior changes (n=39; 97.5%). For example, participants noted that parents purchased treadmills or gym passes, enrolled teens in sports or other fitness activities, and engaged in physical activities with their adolescents. One adolescent said, “It was a family thing…we would go the gym all together and things like that. Because it was our whole family doing it, it made it a lot easier for us all to stay with it.” Adolescents agreed that “having a partner or a buddy to exercise with helped.”

Parents also often made alterations to their home environment, including increasing availability of fruits, vegetables, and healthier variations of common household foods (e.g., skim milk and whole wheat bread) and decreasing availability of processed and energy-dense foods (n=32; 80%). Parents either prepared or provided the adolescents with resources to prepare their own healthier meals. Adolescents noted that these changes made the weight loss process easier: “[Parents should] watch what they buy. If you are trying to lose weight, it's really hard not to give into temptation.” Adolescents also noted that it was helpful when parents retained healthy aspects of the home environment that existed before they attempted to lose weight, such as cooking healthy meals at home, limiting the amount of sweets brought into the home, and remaining physically active (n=38; 95%).

Adolescents indicated that recognition of positive changes was helpful, particularly when comments came from respected individuals and those who may have teased the teen in the past (n=24; 60%). Acknowledgement of positive changes took many forms, ranging from appearance-related comments (e.g., “you look really good today”) to complimenting the teens' behavioral changes (e.g., “man we need to eat more like you”) to explicitly noticing weight loss. One teen stated:

“You notice the first 5 pounds, but other people notice the next 10, but then strangers on the street notice the next 15. And people are like, ‘hey it looks like you've slimmed down and lost a bit of weight.’ And it was only 10 pounds, but it was good to have people randomly tell me.”

Friends also provided motivation for the teens by giving compliments, working out with the teen, encouraging the teen to continue their efforts, and providing the teen with information on how to lose weight healthfully (n=28; 70%). Friends were often aware of the teen's goals and encouraged the teen to make decisions that were consistent with those goals, such as decreasing sedentary activities, choosing healthier fast food options, and providing emotional support.

Theme IV: Negative Environmental/Social Factors

Some family and peer influences were identified as creating barriers to weight loss. Notably, these behaviors were generally the opposite of those environmental factors identified as positive. For example, participants indicated that parental criticism of the teen's appearance, nagging the teen about weight loss, or comparing the teen to other family or friends were unhelpful strategies (n=25; 62.5%). Participants specifically said: “You can't just come out and be like ‘You're overweight’ because then they take that to heart”; “Making fun of them really doesn't help because I think that makes them more upset and depressed”; and “It's not helpful to have someone telling me why I should want to lose weight.” Home environment factors that created weight loss barriers included parents bringing unhealthy food into the home, buying food in large containers, and making unhealthy meals for the teen. Additionally, participants stated that parental expectations for teen weight loss were hard to meet when parents were not modeling changes themselves. Despite the negative aspects of the environment, teens still were able to lose weight:

“In terms of changing my environment, it was something that I couldn't change the feelings of my family…but what I can change is myself, my interaction with the situation and that's what I did, I just walked away from it.”

Peer pressure to lose an unhealthy amount of weight loss or failure of friends to support the teen's weight loss also were described as barriers to success (n=24; 62.5%). Teasing and sentiments, such as “you only live once,” were identified as discouraging. Many of the adolescents described handling negative peer influences by confronting victimization and deciding not to let others influence their goals.

Discussion

Research examining factors that facilitate long-term success in adolescent weight control is limited. The current study adds to this literature by using qualitative methods to characterize the experiences and strategies of successful adolescent weight losers. These results have potential to inform and improve existing adolescent weight control treatments.

Successful adolescent weight losers endorsed many behavioral strategies that have been shown to facilitate weight loss among adults. These strategies include self-monitoring, increasing PA, reducing consumption of high-calorie foods, using portion control, and eating preferred high-calorie foods infrequently and in small portions. Taken together, these results suggest that successful teen weight losers' behavioral strategies mirror those promoted in existing behavioral weight control programs.⁷

Analyses of motivations for weight control yielded several novel findings. First, the most commonly endorsed motivators for weight loss included desires for better health, increasing subjective self-worth, and accomplishing personal goals. Second, social transitions (e.g., from high school to college) appear to represent periods of increased motivation for weight loss, which may make these intervals ideal for initiating adolescent weight loss interventions. Third, although many teens endorsed desire for improved physical appearance and social acceptance as motivators, these were less common than intrinsic motivators. Although our study sample comprises a unique population of voluntary successful weight losers, these results indicate that intrinsic motivation may be central to adolescents' weight loss success and provides some preliminary support for the hypothesis that external pressure for weight loss (e.g., parental over involvement) is not conducive to adolescent weight management.²⁹ Moreover, this finding is consistent with developmental science, which indicates that adolescents' autonomous decision making facilitates behavior change.³⁰

Although intrinsic motivation was important for initiating weight loss, our findings indicated that adolescents valued supportive parent and family involvement in their ongoing weight control efforts. Consistent with past literature, the majority of participants indicated that parents and siblings adopting healthier PA and dietary habits facilitated the teen's own weight loss.^13,14,16 However, family behaviors, including weight criticism, unwanted oversight of diet and PA, and availability of highly palatable, calorically dense foods, were viewed as barriers to weight loss success. Although adolescence is characterized by relative autonomy from family members, parental and family involvement in making lifestyle changes remain critical factors to adolescents' weight loss success and maintenance. Interventions should encourage family-based lifestyle changes while supporting adolescent's decisional autonomy.

Peer influences were widely endorsed as central to weight loss success. Specifically, motivational support and encouragement by friends for the teen's adoption of healthier behaviors were identified as helpful. Similarly, praise from peers regarding initial success was a powerful motivator to continue weight loss efforts. However, similar to family and parental involvement, discouraging remarks regarding weight status by peers was identified as detrimental to adolescents' weight loss success. Integrating peer support into weight control interventions may be helpful.³¹ For example, recruiting supportive peers to participate in PA and provide praise and encouragement may be an important component of weight loss for adolescents.

Comparing results from our study to research conducted with adults who have lost weight revealed interesting similarities and differences. Lifestyle changes identified in this study, including modification of diet and increase in PA, are common across adolescents and adults. The major distinction between teen and adult weight losers, however, is the strategies used to monitor weight status. Though frequent weighing was shown to be common among adults who achieved weight loss²³ and to be related to caloric intake in adolescents,³² only 5 of our 40 participants endorsed this behavior. Instead, adolescents reported attending closely to dietary plan adherence, PA frequency/intensity, and other indicators of weight (e.g., clothing fit) to facilitate staying on track with weight control goals. These findings indicate that successful weight control among adolescents involves frequent monitoring of behavioral and body-size indicators and may be less dependent on weight monitoring, compared to adults. Adolescents may be more responsive to functional weight-related outcomes (e.g., clothing fit) than to numeric weight feedback. These data support increased attention to nonweight outcomes as indicators of weight loss success in weight control interventions.

Several limitations of this study should be considered. First, participants were individuals who self-identified as successful weight losers and were interested in sharing their strategies with others. Second, the sample primarily comprised older (mean age=17.87; standard deviation=1.54), female (79%), Caucasian (82.5%), and middle-to-high socioeconomic status (SES) adolescents and young adults. Thus, selection bias may limit the generalizability of our findings, particularly given that our study sample is not representative of many groups with high rates of obesity (e.g., low SES, African Americans). Finally, although the semistructured interview offered participants the opportunity to discuss topics beyond the initial prompts, important experiences and domains may not have been captured.

Conclusions

In conclusion, findings from this study suggest that efforts to encourage weight loss among overweight/obese adolescents should focus on identification of intrinsic motivators, particularly related to health and self-worth. Our results also suggest that intervening during sensitive periods (e.g., transition from high school to college) may increase adolescent motivation for weight loss. Once initiated, adolescent weight loss efforts appear to benefit from instrumental and emotional social support, as well as positive commentary from parents and peers.

Footnotes

Acknowledgments

All individuals who contributed significantly to this work are acknowledged as authors.

Author Disclosure Statement

No competing financial interests exist.

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