Behavioral Weight Loss Intervention Preferences of Adolescents with Overweight/Obesity

Abstract

Background:

Behavioral lifestyle interventions are the foundation of adolescent obesity treatment. Tailoring an intervention using adolescent stakeholder engagement during the development process could improve intervention effectiveness.

Methods:

Adolescents with overweight/obesity ages 14–19 (n = 41) participated in 11 sex-specific focus groups (girls = 6, boys = 5) and were asked their preferences regarding who should lead the intervention and be involved, what the messaging of the program should be, how to make the program engaging and maintain participation, and how to best measure nutrition intake and activity. Transcripts were coded and analyzed for emergent themes.

Results:

Mean age was 16.0 ± 1.8 years and participants were racially/ethnically diverse. Adolescents preferred interventions that avoid a focus on “weight loss,” and instead emphasize “healthy lifestyle,” which represents a more comprehensive goal of targeting physical and mental well-being. Most participants indicated preferences for a relatable instructor with prior weight loss experience. Both sexes preferred optional parental involvement, as some parents were described as helpful, while others were perceived as a hindrance to success. Boys and girls identified incentives, engaging activities, and electronic communication as core components for engagement and retention, with girls emphasizing socialization and building relationships. Sex differences in preferences were observed. Girls had more concerns about intervention participation and preferred interventions to be sex stratified.

Conclusions:

Behavioral interventions to treat adolescent obesity should focus messaging/content on healthy lifestyles, rather than weight loss, and be sex stratified. Development and implementation of future behavioral interventions for adolescent obesity should consider tailoring to adolescent preferences when possible to improve feasibility, acceptability, and effectiveness.

Introduction

The prevalence of overweight/obesity (OW/OB) among U.S. adolescents has been increasing steadily over several decades.^1–3 Excess adiposity in youth often extends into adulthood,⁴ which may have severe effects on long-term mental and physical health.^5–7 Given these implications, adolescents with OW/OB should be provided with effective treatment options to manage chronic disease.^2,3

The foundation for adolescent obesity treatment is behavioral lifestyle intervention.^2,3 Moderate evidence indicates that strengthening adolescents' cognitive beliefs, such as attitudes and intended choices, improves lifestyle behaviors.^8,9 However, behavioral weight loss treatments to date have led to modest weight loss,^10–12 with a reduction in weight of ∼3.67 kg.¹⁰ Additionally, while obesity in adolescents often includes various psychological complications, these comorbidities are minimally addressed in behavioral lifestyle interventions.^13,14 Adolescence is marked by mental, emotional, and hormonal fluctuations with significant psychological transitions, such as increased autonomy, while self-regulatory skills remain limited.¹⁵ Despite this unique developmental period, there is a paucity of behavioral interventions that appear to have sought adolescent input in design and development based on what can be found in the literature.¹⁶ Adolescent interventions also face problems with fidelity and high attrition rates.^9,17,18

One possible strategy for improving an intervention's feasibility, acceptability, and effectiveness is to incorporate patient input. Patient input can be harnessed through stakeholder engagement during the intervention development process.¹⁹ By engaging stakeholders, the relevance of an intervention, whether through a cultural or community context, increases, which can lead to greater treatment exposure through improved fidelity.²⁰ A systematic review synthesizing qualitative data from adolescents upon completion of behavioral obesity interventions shows that tailoring to adolescents' unique needs is important for success.²¹ Thus, the objective of this qualitative study was to identify preferences of adolescents with OW/OB for a behavioral weight loss intervention to create an acceptable and effective intervention.

Methods

Focus groups were conducted with racially/ethnically diverse adolescents with OW/OB. Data described herein will be used as part of a larger study to develop, implement, and test the feasibility and acceptability of an adolescent acceptance-based therapy intervention for adolescents with OW/OB. The focus group results discussing barriers/facilitators to weight loss and living a healthy lifestyle are described elsewhere.²² The purpose of this analysis is to elicit adolescent preferences for components of a behavioral weight loss intervention. Specifically, the primary objectives of the study were identified a priori and included assessing (1) adolescent preferences regarding who should lead the intervention, (2) who should be involved, (3) where the program should take place, (4) what the messaging of the program should be, (5) how to make the program engaging and maintain participation, and (6) how to best measure nutrition intake and activity. Based on our literature review and clinical experience, we identified these factors as critical research gaps within the adolescent behavioral treatment of obesity literature. This study received Institutional Review Board approval (IRB201701609).

Participants and Recruitment

Adolescents ages 14–19 were recruited for 10 sex-stratified focus groups (n = 41; 28 females, 13 males) in 2018–2019. Potential participants were identified using an Integrated Data Repository (IDR) containing electronic medical record information from patients in the health system. The IDR permits researchers to run queries with inclusion and exclusion criteria to identify potentially eligible participants who are enrolled in the “Consent2Share” program and contact them for research opportunities. Participants may or may not be treatment seeking for their OW/OB. Each person identified was mailed a postcard with study information and subsequently contacted by trained study personnel. Participants were also recruited through flyers posted in pediatric clinics and around the community. A telephone screening was completed to assess eligibility of those interested in participating through collection of self-reported height/weight. Those with a BMI ≥85th percentile for sex and age as determined by CDC growth charts were eligible for study inclusion.²³ Exclusion criteria included ≥5% of weight loss in the past 6 months, diagnosed diabetes, any condition prohibiting physical activity, diagnosed clinical depression, known substance abuse or eating disorder, pregnancy, and any major health condition or medication known to affect body composition or appetite as established through self-report in the telephone screening. During study recruitment, 193 telephone screenings were completed to assess eligibility. After screening, 117 potential participants were excluded, 35 opted not to participate, and 41 participants completed the study.

Design

Focus groups were conducted in a research facility with the moderator using a semistructured, open format interview guide with topics as follows: concerns related to attending a weight loss intervention, intervention instructor and others who should be involved, intervention logistics, intervention messaging, dietary intake and activity measurement, and adolescent engagement.²⁴ Comoderators took observational field notes and each focus group lasted 60–90 minutes. A demographics survey was given to all participants at the conclusion of the discussion. With the exception of one focus group, each was sex stratified with sex-concordant moderators (M.I.C., A.M.L.) to increase participant comfort while speaking about potentially vulnerable topics. Moderators and comoderators were trained in focus group methods, ways to avoid weight-related bias, and cultural competence. Each focus group was audiorecorded and subsequently transcribed, then reviewed to ensure accuracy. Once thematic saturation was met across groups, as defined no new themes being presented by the groups, focus groups were concluded.

Analysis

All study members were trained on content analysis a priori and guided through the analysis by a qualitative expert (S.M.S.). Transcripts were independently read by all members of a coding team (A.M.L., D.R.M., J.R.D., A.D.) to generate themes for codebook creation using inductive/deductive analytic approaches for content analysis.^25,26 Codes were developed using a robust system consisting of the following components: detailed description, inclusion/exclusion criteria, typical/atypical exemplars, and a “close, but no” example, guiding reliable and valid application throughout all transcripts. The codebook primarily included a flat framework to permit intersections, if relevant, of descriptive codes created from discussion topics and thematic codes identified in transcript review. Hierarchical codes were included to identify types of people, places, and preferences. Using MAXQDA 2020 (Verbi Software, Berlin, Germany), codes were applied to one male and one female transcript by two pairs of coders and interrater reliability was measured with coefficient Kappa (κ).²⁷ The codebook underwent iterative changes and clean transcripts were recoded until κ ≥ 0.61, recognized as substantial agreement. A second round of coding with new coding partners and two new transcripts was completed to ensure consistency and appropriate presentation of main ideas set forth. Analyses were run to capture themes from the total sample and sex-specific samples, given that sex differences were observed in previous work.²⁸

Code frequencies were analyzed and examined, generating visualizations for code intersections (co-occurrence). Quote selections were identified for each theme using complex coding queries, pulling relevant retrieved segments. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to report this research.²⁹

Results

Participant Demographics

Focus groups were conducted in six female and five male groups with group size between 2 and 7 participants. Mean age was 16.0 ± 1.8 years and participants were racially/ethnically diverse (56.1% White, 36.6% Black/African American, 4.9% Asian, 2.4% mixed race; 14.6% Hispanic). Additional demographics are provided in Table 1.

Table 1.

Participant Demographics by Sex

Variable	All (n = 41)	Sex
Variable	All (n = 41)	Female (n = 28)	Male (n = 13)
Age (years, mean ± SD)	16.0 ± 1.8	15.9 ± 1.8	16.3 ± 1.8
Sex (% female)	68.3	68.3	31.7
Race (%)
White	56.1	60.7	46.2
Black or African American	36.6	28.6	53.8
Asian	4.9	7.1	0
Multiple races	2.4	3.6	0
Ethnicity (%)
Hispanic/Latino	14.6	14.3	15.4
Not Hispanic/Latino	80.5	85.7	69.2
Did not answer	4.9	0	15.4
Parental education (mother) (%)
Some high school	7.3	7.1	7.7
High school diploma/GED	7.3	10.7	0
Some college	14.6	14.3	15.4
Associate degree	12.2	7.1	23.1
College graduate	29.3	25.0	38.5
Graduate/professional degree	19.5	21.4	15.4
Do not know	9.8	14.3	0
Parental education (father) (%)
Some high school	7.3	7.1	7.7
High school diploma/GED	17.1	7.1	38.5
Tech or vocational school	4.9	0	15.4
Some college	12.2	17.9	0
Associate degree	0	0	0
College graduate	19.5	25.0	7.7
Some graduate/professional school	2.4	3.6	0
Graduate/professional degree	9.8	10.7	7.7
Do not know	26.8	28.6	23.1
Reported school (or community) Subjective social status	6.4 ± 1.9	6.4 ± 1.9	6.4 ± 2.0

Themes

Participant responses were organized into five emergent themes: instructor and parental involvement preferences, intervention messaging, intervention engagement, and concerns with attending a weight loss intervention. Sex differences were identified where applicable and κ was ≥0.61 and ≤0.77. Table 2 shows all of the quotes in full that are used to support each theme.

Table 2.

Example Quotes for Each of the Main Themes

Instructor
“I think just overall, someone relatable…whether that's our age, they've been through it, things like that. Just being relatable would be the main thing…” (#27, female group 5, age 15)
“I think someone who has experience with losing weight, and like some background, about—like someone who has had struggle in their past.” (#36, male, group 5, age 16)
Female-Specific
“…for some people, if the person leading it had a super-athletic body type and you have more of a curvy body type and you know you're never going to be able to achieve that, just because you're shaped differently and you have different metabolisms and that could kind of almost turn people off…” (#18, female group 3, age 17)
Parental Involvement
“Sometimes, you might want your parents there for support and then, sometimes, you might want to branch off on your own a little bit.” (#1, female group 1, age 14)
“I feel like parents need to be kind of educated on how to support us through this and what to say and what not to say. Then, I also think that there needs to be one where it's both because they need to hear what other people are going through, too, so it doesn't just seem like we're being bad kids.” (#5, female group 1, age 16)

Intervention Messaging
I do personally like the word “lifestyle,” just because it takes away from the emphasis of like weight loss and that. It makes you feel like you're going into something, like, “Oh, I'm going to change my life, and I'm just going to be overall happier.” (#31, female group 5, age 19)
“Not obese just you're—just healthy. Like you're eating the right stuff, you're exercising, you're doing everything you need to do that can help you have a—just a good long life.” (#41, male group 4, age 15)

Intervention Engagement
Activities
“Change it up, just like have activities in different places and stuff like that. If you change the places over time, a lot of kids would want to stay in it, because they want to see where the program's going.” (#24, male group 2, age 16)
Female-Specific
“It would also give people more opportunities to find friends that are in the same program and going through the same thing. It could be better for teens because we feel like, okay, we can be friends and we know what we're both going through. Now, you have somebody to encourage you and be there for you.” (#2, female group 1, age 15)
Incentives
“Definitely having an incentive. If you come to the program this many times or if you go out, even outside of the study, like work out or work on a healthier lifestyle, like you can get points and have a point system, or something like—to have an incentive at the end.” (#15, female group 3, age 19)
Because all the things that teenagers are - that we - it's sad to say this, but we really want material things that would cost too much or are really hard to get.”(#23, male group 2, age 16)
Electronic communication
“My winter guard program, we have an app called Remind, and that like sends out messages like let's do this, we're doing this and this, prepare, and have fun. It motivates us and it like really keeps me like okay, they really want us to work hard.” (#21, female group 4, age 17)
“Tell them how glad you are to have them in the program and check up on them during the week and stuff.” (#36, male, group 5, age 16)

Concerns Related to Participating in a Weight Loss Intervention
“I guess just it not being like adaptable to like everything we have to do…like just the fear of it not being like realistic to do a plan on top of everything else.” (#27, female group 5, age 15)
Female-Specific
“I think that if it just starts off the bat really difficult and making you exercise a lot, instead of gradually working up to it, it's not going to… I won't want to do it because it's just going from nothing to really difficult is stressful and doesn't seem… I don't have the motivation for it.” (#5, female group 1, age 16)
“Sometimes, maybe people that go to your school or something could be attending it, and then they go and tell other people, and then you start getting bullied or something for attending it or something. Then, it makes it harder for you to even attend it or lose the weight…” (#2, female group 1, age 15)
“Girls, being with other girls is kind of more comfortable because some of the girls could be going through the same thing as you, to where as boys sometimes don't see things from girls' point of view.” (#2, female group 1, age 15)
“I feel wrist [accelerometer placement] because I feel like it's more discreet and it could just be a watch, so you don't have to tell people what it is constantly.” (#5, female group 1, age 16)

Instructor

When asked who should lead the intervention, adolescents emphasized the importance of a relatable instructor.

I think just overall, someone relatable…whether that's our age, they've been through it, things like that. Just being relatable would be the main thing… (#27, female group 5, age 15)

Relatability was described as someone with prior weight loss experience and someone “younger” or “closer to their age,” identified as 20s or 30s. Prior weight loss experience and knowledge of nutrition and physical activity were perceived as important qualifications to lead the intervention, but a specific degree was not considered necessary. Adolescents reported that the instructor should be “motivating,” “positive,” and “not harsh.”

I think someone who has experience with losing weight, and like some background, about—like someone who has had struggle in their past. (#36, male, group 5, age 16)

Female Specific: Body size was also discussed in the context of an instructor's experience with weight loss and considered part of an instructor's relatability with female participants. Instructors who did not have a healthy body size or were considered too athletic or small to be attainable for participants were described as discouraging. Some females extended relatability to sex, stating “It would be easier to trust a female,” and there are “different things that females or males go through” that would increase comfort for females to talk with a female instructor. However, other adolescents stated sex of the instructor “doesn't matter.”

Parental Involvement

When asked if parents or other people in the adolescents' lives should be involved in the intervention, consensus that relationships with parents are different for everyone was provided; thus, the option to choose was preferred.

Sometimes, you might want your parents there for support and then, sometimes, you might want to branch off on your own a little bit. (#1, female, group 5, age 15)

Both males and females acknowledged parental involvement could be helpful for support at home, increased comfort with attending the intervention, parental health goal achievement, and to better understand the adolescent experience. Many participants reported that parents play a pivotal role in finances and decisions made about food in the home and need to learn what is healthy for their adolescent. However, others felt parents could be a hindrance to intervention success and were concerned about being judged or critiqued by them. One-third of the groups proposed a two-part intervention, one for parents and one for adolescents, so parents could understand what is being learned to provide support, but also to provide adolescents with privacy and independence.

I feel like parents need to be kind of educated on how to support us through this and what to say and what not to say. Then, I also think that there needs to be one where it's both because they need to hear what other people are going through, too, so it doesn't just seem like we're being bad kids. (#5, female group 1, age 16)

Intervention Messaging

Adolescents reported they did not want intervention messaging to include “weight” or “weight loss” as it would “scare people off,” “make me feel overweight,” or “feel judged.” Rather, participants described wanting intervention messaging about “health,” “bettering yourself,” and “feeling better about yourself.” A “health” or “healthy lifestyle” focus was seen as wholly comprehensive, addressing both physical and mental healthy living components.

I do personally like the word “lifestyle,” just because it takes away from the emphasis of like weight loss and that. It makes you feel like you're going into something, like, “Oh, I'm going to change my life, and I'm just going to be overall happier.” (#31, female group 5, age 19)

Intervention Engagement

Intervention engagement was defined as conversations focusing on “methods or concepts relevant to maintaining intervention participation and keeping adolescents focused.” Conversations about engagement included three primary subthemes: activities, electronic communication, and incentives. Although males and females each enumerated these themes as important for engagement, their descriptions of how each should manifest in the intervention differed by sex for some of the subthemes.

Definitely having an incentive. If you come to the program this many times or if you go out, even outside of the study, like work out or work on a healthier lifestyle, like you can get points and have a point system, or something like—to have an incentive at the end. (#15, female group 3, age 19)

Incentives were defined as “motivating factors for participants to continue intervention participation…such as compensation or a valued item.” Both males and females identified incentives as important for adolescent engagement.

Incentives were primarily described as material “rewards” participants could earn through “reaching a goal,” winning a “challenge,” or consistency in attendance. Incentives were perceived as likely to help with intervention engagement and motivation, appealing to the desire for free items, and providing a sense of belonging. Participants acknowledged that identifying an appropriate reward for an adolescent is challenging, especially since common rewards include food; however, many other potential reward suggestions were mentioned.

Because all the things that teenagers are - that we - it's sad to say this, but we really want material things that would cost too much or are really hard to get. (#23, male group 2, age 16)

Adolescents identified field trips, shirts, hoodies, pedometers/Fitbits, fun workouts, phone cases, water bottles, social events, healthy foods, fitness items, drawstring bags, and gift cards as potential incentives.

Adolescents described electronic communication between themselves and the research team as important for maintaining intervention participation. Text and the Remind© app were overwhelmingly identified as preferable forms of communication as compared with phone calls or e-mails. Participants described being more comfortable with answering texts or “reminds,” which do not require an immediate response and are more convenient for busy schedules.

My winter guard program, we have an app called Remind, and that like sends out messages like let's do this, we're doing this and this, prepare, and have fun. (#21, female group 4, age 17)

Tell them how glad you are to have them in the program and check up on them during the week and stuff. (#36, male group 5, age 16)

Participants also identified electronic communication as useful for sending reminders to the entire participant group, informing about upcoming events and weekly assignments, and providing encouragement.

Activities were defined as “things that would be incorporated into the intervention that require action other than discussion or listening to information.” Participants described integration of activities into the intervention as ways to create a fun, interesting environment.

Change it up, just like have activities in different places and stuff like that. If you change the places over time, a lot of kids would want to stay in it, because they want to see where the program's going. (#24, male group 2, age 16)

Activities could include “something interactive,” such as games, field trips, or social events, or “activities that get you moving, that get you active,” including “going for walks” or playing a sport. Discussion of activities also included mention of incorporating “challenges.” “Challenges” were perceived as a source of motivation and fun for those who enjoy being “competitive.”

Female Specific: Females provided an additional purpose for activities directly tied to perceived intervention engagement, which manifested in themes related to “socializing,” “friends,” and “encouragement.” Females described that activities could provide opportunities to build relationships with others for support.

It could be better for teens because we feel like, okay, we can be friends and we know what we're both going through. Now, you have somebody to encourage you and be there for you. (#2, female group 1, age 15)

Concerns Related to Participating in a Weight Loss Intervention

Participants identified several concerns related to weight loss intervention participation. Both males and females described weight discussions as “embarrassing” and expressed concerns about the intervention's practicality regarding how it would fit into their busy schedules.

I guess just it not being like adaptable to like everything we have to do…like just the fear of it not being like realistic to do a plan on top of everything else. (#27, female group 5, age 15)

Female Specific: Females further elucidated concerns on program practicality specific to logistics and program intensity. Females described the added challenge of aligning their schedule with their parents' schedule for consistent attendance. Additionally, it was mentioned that the intervention should be appropriately tailored to an adolescent's body, proposing realistic expectations for nutrition and exercise. Participants were worried about the program being too intense in its recommendations right from the beginning.

I think that if it just starts off the bat really difficult and making you exercise a lot, instead of gradually working up to it, it's not going to… I won't want to do it…. (#5, female group 1, age 16)

Another primary concerns subtheme specific to females was judgment. Females expressed concerns about potential judgment from others if they were in a weight loss intervention and indicated that explaining their activities to peers or friends would be embarrassing.

…then they go and tell other people, and then you start getting bullied or something for attending it or something. Then, it makes it harder for you to even attend it or lose the weight… (#2, female group 1, age 15)

Some females also considered their parents as a concern due to parents being “nosy,” “stressful,” or “critical” of them. Additionally, fear of judgment was not limited to coming from those outside the intervention as they also feared “being judged by other people in the program.” Females did not want to be in an intervention with males as this would add further discomfort.

Girls, being with other girls is kind of more comfortable because some of the girls could be going through the same thing as you…. (#2, female group 1, age 15)

These fears of judgment tie into an expressed desire for privacy, such that external facing aspects of the intervention should be discreet. Females did not want to participate in exercise in places where others could observe. Additionally, responses about the type of food diary preference and where they would prefer to wear an accelerometer during the study were reflective of reducing judgment from others.

I feel wrist [accelerometer placement] because I feel like it's more discreet and it could just be a watch, so you don't have to tell people what it is constantly. (#5, female group 1, age 16)

Discussion

Adolescents with OW/OB articulated several preferences for a behavioral weight loss intervention. Males and females emphasized that the intervention instructor must be relatable, have prior weight loss experience, and be positive and motivating. Females also identified an ideal leader as someone with a healthy, attainable body size, and some suggested the instructor be sex concordant. Adolescents felt parental involvement should be optional, as some viewed parents as helpful while others indicated parents as a hindrance to success; however, participants also recognized their limited autonomy and the potential benefit of parents also receiving intervention education to provide appropriate support. Comprehensive messaging that focused on “health” or “lifestyle” through addressing and integrating physical and mental health was an important distinction, and it was clear that adolescents did not want the focus solely on weight loss. Furthermore, methods of engagement related to activities, incentives, and electronic communication were preferred. Concerns related to attending a weight loss intervention were noted, including embarrassment surrounding weight discussions, time constraints, and females elaborating on judgment from others and unrealistic intervention expectations.

A systematic review of qualitative work synthesizing adolescents' viewpoints upon completion of a weight loss intervention found that adolescents with a lack of family support were more likely to report no success from their respective intervention.²¹ That review highlighted the perceived value of parental support, which could provide motivation, encouragement, and a home environment that aids in success.²¹ Adolescents in this study recommended that parental involvement be an optional component during interventions, as preferences may differ by individual perception of whether parents are a facilitator or barrier to health-related goals. This is consistent with findings in our previous qualitative work, which demonstrated perceptions of parents as both barriers/facilitators to adolescent health.²⁸ This dual role may explain why participants stated parental involvement could be helpful for parental education on how to properly support adolescents, but should not be required as this may not always be preferable. This description of parental involvement would not be considered a family-based intervention because parents are recommended to be more passively involved vs. actively involved.³⁰ Future behavioral weight loss interventions may want to consider providing guidance and resources for parents to support their adolescents at home, while also respect the growing autonomy of adolescents and the multifaceted, differing relationships of families by leaving parent involvement in the program up to the participant.

Although weight loss is considered one of the key clinical endpoints for obesity treatment to improve cardiometabolic risk,^2,3 adolescents did not want the intervention to focus solely on weight, but rather on overall physical and mental health. Outcomes in our focus groups are consistent with a qualitative study demonstrating that conversations led by doctors should not be “weight focused,” but “health focused,”³¹ but to our knowledge, this is the first study reporting that eligible participants for an adolescent behavioral weight loss intervention do not want the messaging and focus of the program to solely be about weight loss. Given that behavioral weight loss interventions are a form of medical treatment for OW/OB, researchers and clinicians conducting interventions for adolescents may want to consider using terminology that removes the focus on weight and instead emphasizes overall health. This was successfully implemented in a school-based behavioral intervention that used cognitive/behavioral skill building to initiate healthy lifestyle behaviors, which resulted in significant reductions in BMI.⁹

The focus groups described herein and prior evidence from a systematic review with adolescents who completed participation in a weight loss intervention emphasized the importance of active engagement through fun activities.²¹ These data add information on the potential importance of incentives to help with motivation, retention, and engagement. It is important to distinguish that most participants were not referencing compensation for research and that incentives were seen as a separate component of intervention engagement. Therefore, these data suggest that material incentives could be a useful addition in adolescent behavioral weight loss interventions along with research compensation, and future work should seek to utilize designs that permit measurement of the impact of these incentives on intervention effectiveness.

Previous interventions for healthy eating found that different curriculums and strategies are effective for male and female adolescents.^32,33 Similarly, sex differences were also observed herein regarding preferences for intervention instructor, engagement, and concerns for participating in a weight loss intervention. Given these findings and previous post-treatment research among adolescents emphasizing the importance of tailored interventions,²¹ it may not be advisable to create a weight loss intervention combining males and females or use the same curriculum for both sexes. Rather, these data and others^28,32,33 indicate that perceived barriers/facilitators and intervention preferences differ greatly by sex. Taken together, evidence suggests that adolescent behavioral weight loss interventions may benefit from being created uniquely for females or males. However, it is important to note that there are successful interventions that are not differentiated by sex and this sentiment may vary widely across different demographic groups and developmental stages.^9,34 Further research is needed to assess the feasibility and acceptability of sex-specific interventions and to identify factors that improve overall effectiveness.

This study has many strengths, including diverse adolescent participants with OW/OB to identify their preferences in development of a weight loss intervention. Furthermore, this research provides important insight that could further improve fidelity in future interventions. Although all participants met clinical criterion for OW/OB through self-reported height/weight, sex, and age, making them medically defined stakeholders, many of the male participants did not perceive themselves to have OW/OB or weight-related struggles.²⁸ This manifested itself through their word choice as they used more third-person pronouns and spoke about other adolescents' perspectives and experiences instead of their own. Future research should explore at what BMI percentile do males become more than medically defined stakeholders, but also become treatment seeking. Preferences may differ when male participants consider themselves to be part of the patient population. An additional limitation is the lack of male-specific themes, which may result from the smaller sample size of boys or from differences observed between boys and girls (i.e., the girls in the focus groups spoke a great deal more than the boys in the focus groups did).

Conclusions

Behavioral interventions to treat adolescent obesity should be tailored where possible to adolescent preferences for the instructor, messaging, and content. Messaging can include focus on both physical and mental health components of healthy lifestyles rather than weight loss alone, and interventions could be sex stratified to account for differences in concerns and aspects of socialization and support. To improve engagement and retention, interventionists may want to consider incorporating incentives, electronic communication, and activities. Development and implementation of future interventions should strive to be based on adolescent needs, and evaluation needs to be conducted to assess which changes and factors improve feasibility, acceptability, efficacy, and effectiveness for adolescents with OW/OB.

Footnotes

Funding Information

This work is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH; UL1TR001427). Dr. Cardel is also supported by the National Institutes of Health National Heart, Lung, and Blood Institute (K01HL141535 and R25HL126146).

Author Disclosure Statement

Dr. Michelle Cardel has conducted paid consulting for WW and unpaid consulting for NovoNordisk.

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