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Article
Abstract
This study evaluated the influence of overweight adolescents lifestyle on the adherence to weight
control, and identifies their predictors. Participants were 94 adolescents, aged 1218 years, attending a
Paediatric Obesity Clinic. Lifestyle was assessed using the Adolescent Lifestyle Profile and treatment
adherence through the Therapeutic Adherence to Weight Control Questionnaire. Adherence to
weight control was associated with various lifestyle domains. Several predictors were identified for
lifestyle and adherence to weight control among overweight adolescents. A broad array of intercorrelations and predictors were identified and should be taken into account when designing adolescent
weight control interventions.
Keywords
adherence to weight control, adolescents, lifestyle, overweight, predictors
Introduction
The prevalence of overweight and obesity
among adolescents has dramatically increased,
both in developed and developing countries
(Carmo et al., 2006; Huang et al., 2013; Machado
et al., 2011; Oude Luttikhuis et al., 2009; Padez
et al., 2005; World Health Organization (WHO),
2002, 2006).
Childhood and adolescence are critical periods for establishing a pattern of healthy behaviors and adoption of a healthier lifestyle
(Commission of the European Communities,
2005, 2007). By the age of 15 years, many adolescents show a reliable level of competence in
metacognitive understanding of decision-making,
creative problem-solving, correctness of choice,
and commitment to a course of action (Mann
et al., 1989). There is evidence that the implementation of strategies to prevent or reduce obesity prevalence may lead to significant gains in
health outcomes (Pereira and Mateus, 2003;
Steele et al., 2008). It is important to emphasize
the central role of lifestyle in the understanding
1Polytechnic
Corresponding author:
Pedro Sousa, Escola Superior de Sade, Polytechnic
Institute of Leiria, Campus 2, Morro do Lena, 2411-901
Leiria, Portugal.
Email: pedro.sousa@ipleiria.pt
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Methods
Study design and participants
A cross-sectional correlational study was conducted. It was hypothesized that a higher BMI
z-score would be associated with a worse
health-promoting lifestyle and a worse adherence to weight control. It was further hypothesized that a greater health-promoting lifestyle
was associated with a better adherence to
weight control among overweight adolescents.
We further hypothesized that lifestyle and
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Sousa et al.
adherence to weight control were influenced by
demographic, anthropometric, behavioral, and
clinical variables.
Study participants were enrolled through an
ongoing longitudinal study on adolescent obesity and monitored by a quarterly survey. This
study was conducted with the data from the
baseline evaluation. Survey methods have been
described in detail elsewhere (Sousa et al.,
2013b). Participants (n = 94) were adolescents
included in a Paediatric Obesity Management
Program in Portugal, aged between 12 and 18
years, fulfilling the Centers for Disease
Controls (CDC) criteria for overweight (BMI
percentile 85th). Exclusion criteria were the
presence of severe psychopathology, inability
to communicate in writing, pregnancy, and having been proposed for bariatric surgery. The
program consisted of clinical assessment, medical, psychological, nutritional, and physical
activity counseling. Sample recruitment had the
support of the clinical staff. All eligible adolescents with appointments between 1 January and
31 December 2012 were included.
Procedures
This study was approved by the Ethical Committee
for Health (Lisbon, Portugal) in January 2012 and
founded by the Foundation for Science and funded
by the Fundao para a Cincia e a Tecnologia
(Portugal) (PTDC/DTP-PIC/0769/2012). All eligible adolescents and respective parents signed an
informed consent where the study objectives were
explained. Confidentiality and voluntary participation were assured. Those who signed the
informed consent were given a brochure with a
summary of relevant information and e-contacts
needed to enable them to fill out the data collection instruments online. The option of responding
to the initial questionnaire on paper was also provided at the clinic.
Measures
Data were collected during 2012 from different
sources: clinical files (demographic, anthropometric, behavioral, and clinical variables) and
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Data analysis
Missing data at baseline were determined
using the expectation-maximization method
(by including data from the second wave of the
ongoing longitudinal study). Descriptive statistics, including measures of frequency, central tendency, and distribution were used to
describe the sample characteristics and study
variables.
Nonparametric tests were used in inferential
statistics, due to a non-normal distribution of
the data. Spearman correlation, MannWhitney
U test, and KruskalWallis with Bonferroni
correction were used to assess the associations
between the variables and test the hypothesis.
All analyses were conducted using the SPSS
v.18 software. A p value of .05 was used to control the type I error rate.
Results
The characteristics of the sample are described
in Table 1. The mean BMI z-score was 2.065
(standard deviation (SD) = 0.377), corresponding to a mean BMI percentile of 97.362 (SD =
2.193). Parents with a higher education were a
minority (6.40% fathers; 10.00% mothers) and
most parents worked in services and sales
(25.60% fathers; 28.20% mothers). The high
percentage of unemployed parents (11.50%
fathers; 9.00% mothers) was noteworthy.
Statistically significant differences between
genders were only found for screen time (U =
157.000, p = .033), with boys spending more
time in front of screens (24.820 11.709 vs
17.625 10.454).
The overall lifestyle score was 2.604 (SD =
0.386), using a four-point scale. The analyses of
the subscales showed the highest values for
Interpersonal Relationship and Positive Life
Perspective and the lowest for Spiritual
Health, Health Responsibility, and Physical
Activity.
Regarding weight-control adherence (scale
range: 15), the overall nonadherence score
was 2.506 0.864, while for the overall treatment adherence score, the value rose to 3.730
0.576. Of note are the high levels of Perceived
Benefits and Parents/Providers Influence.
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Sousa et al.
Table 1. Descriptive statistics.
Variables
Boys (N = 46)
Girls (N = 48)
Total (N = 94)
Age, years
SD
SD
14.457
1.441
13.896
1.533
14.170
2.157
95.692
92.000
0.360
14.643
3.114
1.989
96.980
91.848
0.364
2.177
3.337
2.065
97.362
91.797
5.278
24.820
4.060
3.708
5.714
4.411
11.709
.982
1.151
0.854
3.596
17.625
3.789
3.632
5.371
2.410
10.454
0.976
1.116
0.877
4.497
21.622
3.943
3.674
5.524
26.214
6.097
77.694
43.861
28.536
3.451
26.819
30.286
19.878
6.969
76.171
38.114
23.603
3.554
21.942
26.680
23.084
6.496
77.000
40.250
3.266
4.450
3.415
4.230
3.724
2.676
0.866
0.481
0.844
0.775
0.578
0.955
3.197
4.494
3.542
4.241
3.736
2.344
0.807
0.683
0.777
0.975
0.581
0.741
3.230
4.473
3.480
4.236
3.730
2.506
2.228
2.598
2.862
2.940
2.924
2.915
1.828
2.599
0.578
0.611
0.423
0.642
0.524
0.580
0.646
0.375
2.319
2.240
2.710
3.200
3.255
2.982
1.801
2.610
0.594
0.705
0.540
0.571
0.520
0.505
0.640
0.400
2.274
2.417
2.785
3.072
3.091
2.949
1.815
2.604
Anthropometric variables
BMI z-score
BMI percentile
Waist circumference percentile
Behavioral variables
Weekly physical activity (h/w)
Screen time (h/w)
Family support
Weight-loss motivation
Body image silhouette
Clinical variables
Time elapsed since first visit (months)
Age at onset of obesity (years)
Systolic blood pressure percentile
Diastolic blood pressure percentile
Adherence to weight control
Self-efficacy/adherence behaviors
Parents/providers influence
Friends/school influence
Perceived benefits
TAWC total score
Risk of nonadherence
Lifestyle
Health responsibility
Physical activity
Nutrition
Positive life perspective
Interpersonal relationship
Stress management
Spiritual health
ALP total score
ALP: Adolescent Lifestyle Profile; BMI: body mass index; SD: standard deviation; TAWC: Treatment Adherence to
Weight Control.
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Table 2. Correlations between lifestyle, adherence to weight control, and BMI z-score.
r Spearman
HR
PA
PLP
IR
SM
SH
.289**
Total ALP
.528**
.299**
.378**
.109
.306**
.510**
.030
.251*
.448**
.174
.314**
.001
.146
.026
.181
.073
.259*
.065
.163
.011
.391**
.151
.040
.102
.278**
.158
.001
.169
.416**
.242*
119
.004
.136
.150
.111
.046
.362**
.124
.015
.022
.212*
.101
.054
.079
.454**
.229*
.047
.279**
ALP: Adolescent Lifestyle Profile; BMI: body mass index; HR: health responsibility; IR: interpersonal relations; N: nutrition; PA: physical activity; PLP: positive life perspective; SH: spiritual health; SM: stress management; TAWC: Treatment
Adherence to Weight Control.
*p < .05; **p < .01.
higher rates of self-efficacy/adherence behaviors (rs = .528, p < .0001) and overall treatment adherence (rs= .391, p < .0001). Better
nutrition rates appear to be associated with
higher levels of self-efficacy and adherence
behaviors (rs = .299, p = .004), higher parental
and providers influence (rs = .251, p = .016),
and higher overall treatment adherence (rs =
.278, p = .007).
Regarding the positive life-perspective subscale, a positive association was found between
self-efficacy and adherence behaviors (rs =
.378, p < .0001), parental and providers influence (rs = .448, p < .0001), and overall treatment adherence (rs = .416, p < .0001). However,
the positive life perspective showed a negative
correlation with risk of nonadherence (rs =
.242, p = .020).
Presenting better stress management appears
to contribute to higher rates of self-efficacy and
adherence behaviors (rs = .306, p = .003), parental and providers influence (rs = .314, p = .002),
as well as friends and school influence (rs =
.259, p = .013), and even higher overall treatment adherence (rs = .362, p < .0001). Moreover,
the higher the rates of spiritual health, the higher
the self-efficacy and adherence behaviors (rs =
.289, p = .005) and the overall treatment adherence (rs = .212, p = .044).
Lifestyle predictors
Demographic variables.Significant gender differences were found, with males showing
higher rates of physical activity (2.620 0.599
vs 2.228 0.707, p = .013) and females exhibiting higher rates of interpersonal relationships
(3.255 0.526 vs 2.933 0.526, p = .003) and
a more positive life perspective (3.200 0.571
vs 2.940 0.642, p = .050).
Behavioral variables.Adolescents with higher
rates of weekly physical activity presented higher
scores of health responsibility (rs = .307, p =
.005), better nutrition (rs = .372, p = .008), and
higher overall lifestyle score (rs = .389, p = .001).
On the other hand, higher rates of physical inactivity were associated with worse nutrition (rs =
.344, p = .002) and poorer interpersonal relationships (rs = .377, p = .014).
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Sousa et al.
Table 3. Lifestyle predictors.
Variables
Demographic variables
Age (rs)
Gender (U)
Mothers education (H)
Fathers education (H)
Mothers profession (H)
Fathers profession (H)
Anthropometric variables
BMI percentile (rs)
Waist circumference
percentile (rs)
Behavioral variables
Weekly physical activity (rs)
Screen time (rs)
Family support (rs)
Weight loss motivation (rs)
Body image silhouette (rs)
Clinical variables
Time elapsed since first visit (rs)
Age at onset of obesity (rs)
HR
PA
PLP
IR
SM
SH
Total ALP
.072
977
2.395
1.256
.417
1.766
.163
760.0*
2.665
1.533
3.424
2.841
.194
931
2.315
4.057
2.276
.831
.080
833.0*
6.519
2.928
1.932
6.327
.127
702.5**
5.996
1.848
2.459
.242
.044
993
2.562
4.070
2.356
.698
.107
1038.5
5.883
.763
1.786
2.838
.148
1037.5
3.652
.697
.603
.284
.741
.150
.715
.125
.992
.023
.275
.057
.307
.090
.889
.022
.624
.016
.665
.087
.307*
.197
.250
.198
.200
.527**
.226
.245
.278
.142
.372**
.344*
.142
.204
.027
.220
.109
.005
.155
.152
.211
.377*
.008
.019
.085
.089
.097
.185
.097
.150
.021
.185
.210
.164
.120
.389**
.241
.180
.235
.184
.023
.017
.110
.003
.359**
.143
.147
.009
.160
.104
.147
.118
.079
.041
.165
.042
ALP: Adolescent Lifestyle Profile; HR: Health Responsibility; IR: Interpersonal Relations; N: Nutrition; PA: Physical Activity; PLP: Positive
Life Perspective; SH: Spiritual Health; SM: Stress Management.
rs: Spearman correlation; U: MannWhitney U test; H: KruskalWallis test.
*p < .05; **p < .01.
Adherence to weight-control
predictors
Demographic variables.Significant differences
were found between educational levels of both
parents regarding parental influence on adherence (mother: Higher Education = 4.875
0.222 vs second cycle = 4.313 0.521, p =
.018; father: Higher Education = 4.875 0.177
vs third cycle = 4.251 0.695, p = .037). Significant differences were also found between
parental occupation regarding parental influence on adherence (Executives and intellectual
professions = 4.886 0.163 vs Inactive workers
= 4.417 0.793, p = .037).
Behavior variables.Adolescents who presented
higher rates of family support tended to develop
Discussion
With its focus on weight control, this study
identified a set of lifestyle and treatment adherence predictors. It has long been understood
that lifestyle intervention is essential for successful treatment. A systematic review of
Brown et al. (2009), aiming to determine the
long-term effectiveness of lifestyle interventions in the prevention of overweight and morbidity, showed a significant positive impact on
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SEA
PPI
FSI
PB
Total TAWC
RNAWC
.008
1020.500
.418
.141
1.517
2.702
.109
877.500
11.960*
10.185*
4.048
8.464*
.053
993.500
4.666
2.468
.447
.660
.165
981.000
3.071
2.190
2.177
1.406
.021
1015.000
1.505
1.545
.951
1.729
.046
838.000
1.976
9.192
4.223
3.936
.034
.034
.105
.003
.000
.095
.148
.145
.027
.212
.211
.032
.056
.054
.087
.067
.067
.258*
.223
.202
.295
.297
.079
.097
.005
.226
.034
.025
.028
.048
.080
.065
.008
.064
.101
.170
.269
.119
.162
.081
.247
.159
.040
.175
.141
.430**
.205
.032
.270*
.054
.182
.048
.207
.083
.120
.132
.155
.047
.171
.095
FSI: Friends/Schools Influence; PB: Perceived benefits; PPI: Parents/Providers Influence; RNAWC: Risk of Non-Adherence to Weight Control; SEA: Self-Efficacy & Adherence behaviours; TAWC: Treatment Adherence to Weight Control.
rs: Spearman correlation; U : MannWhitney U test; H: KruskalWallis test.
*p < .05; **p < .01.
weight, blood pressure reduction, type 2 diabetes, and metabolic syndrome risk.
The analysis of the intercorrelations between
lifestyle, adherence to weight control, and overweight revealed that BMI z-score was not the
main factor responsible for lifestyle and treatment adherence, making it necessary to find
other factors that may contribute to this variance.
Unlike previous research, it was not possible to
endorse the assumption that an effective overweight management implies patients adherence
to behavioral changes and a healthier lifestyle
(Elfhag and Rossner, 2005; Sousa, 2010).
Our results indicate that adherence to weight
control is closely related to lifestyle. There is
some indication that health responsibility, physical activity, nutrition, positive life perspective,
stress management, and spiritual health, all
contribute to several domains of adherence,
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Sousa et al.
activity. In this domain, we found interesting
gender differences, with boys showing higher
rates of physical activity, while girls showed
higher interpersonal skills. Higher rates of
weekly physical activity were associated with
higher rates of health responsibility, a better
nutrition, and a higher overall lifestyle score. On
the other hand, higher rates of sedentary lifestyle
were associated with lower interpersonal skills
and nutrition quality. Earlier studies stressed the
importance of promoting physical activity
among overweight adolescents (Stankov et al.,
2012; Ullrich-French and McDonough, 2013).
However, overweight adolescents experience
several barriers to participation in physical
activity, such as physical discomfort and fatigue.
Moreover, stigmatization and peer discrimination can negatively reinforce their negative selfperception,
negatively
impacting
their
psychosocial development and increasing their
psychosocial vulnerability.
In this research, the adherence to weight
control domains that scored higher were benefit perception and recognition of parental/providers influence.
Another important result was the fact that
parents with a more differentiated profession
and higher education seemed to be able to influence more positively the adolescents adherence to weight control. These data are in line
with the WHO (2006) report, which states that
there is an association between overweight and
obesity and lower socioeconomic status, which
in turn contributes to an increase of inequalities
in health.
Findings suggest a positive association
between the waist circumference percentile
and the risk of nonadherence. Interestingly, our
findings indicate that the longer the time
elapsed since the first visit, the lower the selfefficacy for adherence. On the one hand, we
are aware that behavioral changes are complex,
demanding, and usually require long periods of
treatment/monitoring. On the other hand, and
according to the results, it seems that adolescents, as time goes by, start to believe less in
treatment success and in their ability for
change.
Conclusion
These results underline the importance of
behavioral change and the adoption of a healthier lifestyle as pillars for adherence to weight
control. Tailored obesity-management programs should be designed not only according to
adolescent health needs but also taking into
account the broad array of predictors that have
been identified.
Acknowledgements
We gratefully acknowledge the clinical staff of the
Paediatric Obesity Clinic for their dedication. We
also thank all the adolescents and parents for their
participation and collaboration.
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10
Funding
This work was partially funded by Fundao para a
Cincia e a Tecnologia (PTDC/DTP-PIC/0769/2012)
and supported by the Polytechnic Institute of Leiria,
Portugal, and the Department of Paediatrics at
Hospital de Santa Maria, Lisbon, Portugal.
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