Podcast available online at www.jneb.org Research Article Parenting an or Obese Teen: Issues and Advice from Parents Kerri N. Boutelle, PhD1,2,3,4; Shira Feldman, MPH, RD1,2,5; Dianne Neumark-Sztainer, PhD, RD1,2

ABSTRACT Objective: This qualitative study addresses: (1) what challenges parents of overweight adolescents face and (2) what advice parents of overweight adolescents have for other parents. Design: One-on-one interviews were conducted with parents of overweight or previously overweight adolescents. Setting: Medical clinic at the University of Minnesota. Participants: Twenty-seven parents of adolescents (12-19 years) who were either currently or previously overweight recruited from the community. Main Outcome Measures: Qualitative interviews related to parenting overweight adolescents. Analysis: Content analysis was used to identify themes regarding parental experiences. Results: Issues most frequently mentioned were (1) uncertainty regarding effective communication with adolescent about weight-related topics; (2) inability to control adolescents’ decisions related to healthful eating and activity behaviors; (3) concern for adolescents’ well-being; and (4) parental feeling of responsibil- ity/guilt. Parental advice most often provided included: (1) setting up a healthful home environment; (2) pa- rental role modeling of healthful behaviors; and (3) providing support/encouragement for positive efforts. Conclusions and Implications: Topics for potential intervention development include communication and motivation of adolescents regarding weight-related topics, appropriate autonomy, and addressing neg- ative emotions concerning the adolescent’s weight status. Targeting these topics could potentially improve acceptability and outcomes for treatments. Key Words: adolescence, parenting, , overweight (J Nutr Educ Behav. 2012;44:500-506.)

INTRODUCTION Most treatment studies of over- obese. On the other hand, parents weight and obese youth have focused also recognize their adolescent's need The high prevalence and steady in- on the preadolescent age range,6,7 and for autonomy. Thus, parents may creases in overweight and obesity fewer have focused on adolescents.8,9 struggle with what to say or do to among adolescents over the past 30 It can be challenging to know how best help their adolescent manage years are of significant public health to involve parents in interventions his or her weight. concern.1 Overweight and obese ado- for adolescents because of issues Parents have an important role in lescents have an increased risk for related to developing autonomy and helping their children and adolescents physical comorbidities, including increasing independence. Parents of to adopt healthful behaviors.10,11 type 2 , and negative psycho- overweight and obese adolescents Mechanisms by which parents may social consequences stemming from often find themselves in a dilemma. influence eating habits and behaviors the stigma associated with being over- On one hand, parents may be include family meals,12-15 food avail- weight.2 Additionally, overweight concerned about their adolescent's ability at home,16-19 and discussing or and obese adolescents are at a signifi- health, the psychosocial stigmas, and encouraging dieting.20-24 Mechanisms cantly increased risk for obesity in the negative physical consequences bywhichparentscaninfluence adulthood.3-5 associated with being overweight or physical activity levels are parent modeling of physical activity behavior25,26 and support for their 1Division of Epidemiology, University of Minnesota, St. Paul, MN children's physical activity.27,28 2Department of Pediatrics, University of Minnesota, St. Paul, MN Unfortunately, providing this type of 3Department of Pediatrics, University of California, San Diego, CA support can be challenging for families 4Department of Psychiatry, University of California, San Diego, CA and can become especially difficult 5Emily Program, St. Paul, MN when coupled with an adolescent's Address for correspondence: Kerri N. Boutelle, PhD, Pediatrics and Psychiatry, University development of autonomy. To ulti- of California, San Diego, 9500 Gilman Dr, MC 0985, La Jolla, CA 92037; Phone: (858) 534- mately inform interventions, it is 8037; Fax: (858) 534-6727; E-mail: [email protected] important to develop a greater body of Ó2012 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR knowledge related to parenting http://dx.doi.org/10.1016/j.jneb.2011.12.005 overweight and obese adolescents. 500 Journal of Nutrition Education and Behavior Volume 44, Number 6, 2012 Journal of Nutrition Education and Behavior Volume 44, Number 6, 2012 Boutelle et al 501

To the best of the authors' knowl- study if they had ever been diagnosed probing questions were used at the in- edge, only 1 published qualitative with an eating disorder or had any terviewers' discretion to obtain more study has explored experiences of par- physical or psychological condition information from participants when enting an overweight child.29 Jackson (ie, cancer, depression) that could necessary or to clarify participant re- and colleagues interviewed mothers have an impact on weight. sponses. of overweight youth (ages 14 months Parental interviews were conducted Interviews were audiotaped and to 15 years) about their experiences in with 26 mothers and 1 father. The av- varied in length, averaging 30-45 min- parenting. The study found that erage age of the parents was 47.5 years, utes. Tape-recorded interviews were mothers often felt judged and blamed and 74% identified themselves as Cau- reviewed immediately to allow the in- for their child's weight status, were casian, 19% as Native American, and terviewer to summarize and record frustrated with how to best help their 7% as African American. Fifteen per- impressions and note themes ex- child, and worried about their child's cent of parents had an income < pressed by parents. Parents were se- future. Additionally, the mothers all $20,000; 7% of parents had an income lected on a rolling basis until themes identified modeling healthful behav- of $20,000-$40,000; 19% of parents began to repeat themselves and theo- iors as a strategy for helping their chil- had an income of $40,000-$60,000; retical saturation was reached. In- dren. Although the Jackson study has 45% of parents had an income > formed consent was obtained from highlighted some of the issues that $60,000; and 14% of parents did not participants prior to the interviews. parents face when they have an over- report their income. Of the mothers Interviews were conducted between weight child, this study recruited par- interviewed, 20 had female adoles- December, 2004 and November, ents of youth from a wide age range. cents and 6 had male adolescents. 2005, and study procedures were ap- Considering the challenges associated The father interviewed had a female proved by the University of Minne- with parenting adolescents in general, adolescent. All parents lived in the sota Human Subjects Committee. and to identify potential targets for in- Minneapolis/St. Paul metropolitan terventions, it is important to identify area. Fourteen interviews were with Data Analysis issues faced specifically by parents of parents whose adolescent did not lose overweight adolescents. The current weight (adolescent mean BMI percen- Interviews were transcribed verbatim study addresses this gap in the litera- tile ¼ 97.5%), and 13 interviews were from audiotape and were then exam- ture by posing 2 research questions: conducted with parents whose adoles- ined using content analysis techniques (1) what issues do parents of over- cent had successfully lost 10 pounds described by Miles and Huberman.31 weight adolescents face? and (2) and kept it off for 3 months (adoles- Transcripts were reviewed using an in- what advice do parents of overweight cent mean BMI percentile ¼ 87.2%). ductive method to identify emerging adolescents have for other parents? Twenty-two percent of the sample (6 themes. Two main themes, issues par- adolescents) reported that he or she had ents face and advice for other parents, worked with a dietitian. Initially, the 2 were identified from the interviews. METHODS parent groups were analyzed separately Based on these themes, a coding tem- Participants to examine similarities and differences plate was developed. Following discus- in responses between the groups. As sion with the research team, a final Parents of adolescents were recruited the interviews were analyzed, no re- coding template was developed and all from a larger study entitled Successful markable differences were noted in re- interviews were analyzed in entirety to 30 Adolescent Weight Losers, which sponses between the parents of ensure all responses were captured, surveyed adolescents (ages 12-17 adolescents who lost weight and those whetherornottheywereindirectre- years) and their parents to determine who did not: therefore, these groups sponse to questions pertaining to pa- factors contributing to successful were combined for final analysis. rental issues or advice. All transcripts among adolescents. Two were double coded, once by the second groups of overweight and obese adoles- Procedures author and once by an individual with cents were recruited for the Successful expertise in the field of pediatric over- Adolescent Weight Losers study: those One-on-one interviews were conduct- weight and who was not a part of the re- who lost weight and those who did ed with parents at a University of Min- search team. Agreement between the 2 not. Inclusion criteria for the adoles- nesota medical clinic. Questions were coders was calculated using the formula: cent weight loss group included a self- formulated and piloted with a few par- number of agreements/total number of reported loss of at least 10 pounds in ents prior to beginning the study. Two agreements plus disagreements.31 Inter- the past 2 years, maintenance of the trained researchers conducted inter- rater reliability was 90%. Discrepancies weight loss for at least 3 months, and views using standardized interview were discussed until total agreement overweight or obese status (> 85% questions. Parents were asked 8 broad was reached among interviewers. sex- and age-adjusted body mass index questions to explore their experiences [BMI] percentile) before weight loss. in parenting an overweight adoles- Inclusion criteria for the comparison cent (Figure). Interview questions ad- RESULTS group included overweight or obese dressed parents' attempts to help Issues Faced by Parents of status (> 85% sex- and age-adjusted adolescents manage their weight, is- Overweight Adolescents BMI percentile) and no reported sues parents of overweight and obese weight loss within the past 2 years. Ad- adolescents face, and advice parents Participants (n ¼ 27) identified many olescents were excluded from the have for other parents. Additional issues related to parenting an 502 Boutelle et al Journal of Nutrition Education and Behavior Volume 44, Number 6, 2012

Inability to control the adolescent's 1. Can you tell me what kinds of things you have done to help your teen with weight decisions. Parents also discussed frus- management through changes in eating or physical activity behaviors? trations with not being able to control 2. Do you ever worry about your teen’s weight? If so, what are you worried about? their adolescent's decisions about eat- ing and physical activity. Parents 3. What kind of messages do you think you send to your teen about his/her weight struggled with not being with their and weight loss? adolescents all of the time, as well as not being able to force them to make 4. Do you see your teens’ weight as your responsibility or your teen’s responsibility? changes in their eating or activity be- Could you elaborate? haviors. Several parents commented 5. Because teens are becoming independent, parents often struggle with how much that although they could encourage to get involved. Has this been an issue for you? Can you tell me how? their adolescents to make good choices, there was a significant level 6. Sometimes it’s hard to decide if you should focus your efforts only on your child of frustration in the loss of control with weight issues or on the whole family. How do you and your family deal with experienced as their children became this issue? What would you suggest for other families? adolescents and strove for more au- tonomy. A mother of a 14-year-old 7. Many parents of teens want to help their children maintain a healthy weight, but ‘‘ at the same time parents don’t want to make their children feel badly about their girl stated, I'm trying to get her to bodies. Has this been an issue for you? Can you tell me how? get into more exercise, and I've got her on a diet, but I can't be around 8. From your own experiences with your teen, what kind of advice can you give her all the time.’’ She went on to say, other parents for helping teens manage their weight? ‘‘When she goes out of the house or out of my sight, she eats what she's Figure. Parent interview questions for exploring parenting of overweight adolescents. not supposed to eat.’’ The mother of a 17-year-old girl mentioned similar frustrations, ‘‘I'm not with my child 24/7, and if I'm not home and if it's overweight adolescent. Issues most A mother of a 17-year-old girl com- there, she's going to help herself.’’ A frequently mentioned by parents in- mented, ‘‘I try to stress to her what mother of a12-year-old girl said: cluded lack of knowledge about how she needs to do, she has to lose weight, to communicate with the adolescent do some activities.and if I try and tell I could pretty well control what she about weight-related topics (n ¼ 15), her she just gets more annoyed.’’ was eating as a smaller child. Now, an inability to control the adolescent's Parents also struggled with how to less and less. Most nights we have decisions or make decisions for their communicate the importance of dinner together. I will insist she at adolescent about eating or physical changing eating or exercise habits least try the vegetable, and that's activity behaviors (n ¼ 14), a concern without lowering their adolescent's about as far as I feel I can realisti- for the adolescent's well being (n ¼ self-esteem, which was often already cally go with controlling it. 11), and parental feeling of responsi- perceived as low. A parent of a 13- bility for the adolescent's weight prob- year-old girl said: lems (n ¼ 10). Concern for the adolescent's well- I lived through my [older] daughter being. Parents also discussed their feeling insecure about her weight, concerns for their overweight adoles- and just in trying to tell them Communication with the adolescent. cents' physical and mental health. that I think they need to exercise Over half of parents discussed diffi- Several parents felt conflicted in want- more, there were real strong reac- culty in communicating with their ing their children to lose weight and tions from the girls feeling very of- adolescent about eating or weight- be thinner because it would likely fended and hurt. related issues. Parents worried about make life easier, despite knowing being perceived as nagging or annoy- Even parents whose adolescents had that a person's weight was not some- ing, and several struggled with com- successfully lost weight still struggled thing that defined who or what they ments being misinterpreted by with communication issues. One are. Several parents, who were over- adolescents. One parent of a 15-year- mother whose 18-year-old daughter weight themselves, wanted their ado- old girl stated: ‘‘We're very careful had lost weight commented: lescents to lose weight because they not to say anything to her that will understood, firsthand, the physical It's been more of an issue now, set her off or that she can take as crit- and psychosocial consequences of be- when she's put some of the weight icism.’’ Another mother of 15-year-old ing overweight and did not want their back on. You don't want to say girl commented: children to go through a similar expe- anything because she'll just let rience. A mother of a 19-year-old girl I just feel like maybe I'm almost you have it. Even though she had commented: warning her too much because opened the door before on it, they even last night she said, ‘‘I'm sick have to decide for themselves. I Because I'm overweight myself, I of you telling me what to eat and think her dad actually said some- just know how happy, much hap- what not to eat.’’ She's tired of it. thing to her once and she just tuned pier she would be if she's not over- I feel like maybe I should back off. him out. weight, or she's at a better weight, Journal of Nutrition Education and Behavior Volume 44, Number 6, 2012 Boutelle et al 503

closer to where she wants to be. portance of having a healthful home lifestyle behaviors being made by And I really just want that for her. environment to help adolescents their adolescent. Parents felt positive with weight management. Parents be- feedback was important to maintain- Another mother of a 15-year-old girl lieved setting up a household that ing their adolescent's motivation to said: supports a healthful lifestyle would make healthful behavior changes. It's hard, because in the way of the have a positive effect on adolescents' Some parents noted that adolescents world, I think she could be happier behaviors. Many parents discussed may become frustrated with the lack if she wasn't overweight. It bugs having fruit, vegetables, healthful of quick results with weight loss and me because I just think that some snacks, and water available as 1 of they need to be encouraged to con- of the things that she worries about the best ideas for setting adolescents tinue positive behaviors that over wouldn't be such a big worry if she up to be successful in changing eating time will likely result in weight loss. was thinner. habits and losing weight. Some par- A mother of an 18-year-old girl com- ents also felt having exercise equip- mented: ment available for adolescents at Parental responsibility. Many par- I make sure to tell her when I notice home was part of setting up a health- ents struggled with feeling responsi- the healthy behaviors she is doing. ful home environment. The mother ble for their adolescents' weight I know she wants to lose weight of a 17-year-old girl stated: problems. Most parents commented right now, but I know it won't hap- that both parents and adolescents She wanted to join a gym, but it pen as fast as she wants it to. I have a role in making healthful deci- was too expensive. So we went out think giving her good feedback sions, but often parents felt they and got some videos and an exer- about her eating more fruits and should be doing more to instill cise ball and then got a good qual- walking more helps her not give up. healthful habits in their adolescents. ity treadmill, too. So we have it all A mother of a 12-year-old girl said, ‘‘I One mother felt like she was responsi- available at home when she wants think it's more encouragement and ble for her daughter being overweight to use it. and commented: praise when they're doing things A mother of a 12-year-old boy said: right. Kids need to hear that from I feel like I almost gave her that their parents.’’ problem because of the way I cook I think it's important to have or the way I serve. I guess I blame healthy snacks available right myself a lot. Just thinking that if I away. I think just having healthy would have done things differently, food ready so you don't sabotage DISCUSSION maybe she wouldn't have that your child. Just have the healthy This study examined issues faced by problem. I don't know; I made it stuff available and not a lot of parents of overweight and obese ado- too available, made too much food. junk available in the house. lescents and advice for other parents A mother of a 13-year-old girl said: in similar situations. Issues raised by parents included difficulties encoun- Most of the time we don't eat to- Role modeling healthful behaviors. tered in effectively communicating gether. And who's responsible for Parents also discussed the importance with their adolescent about weight- that? Me. The mother is. I've just of modeling healthful behaviors and related topics, perceived inability to been very lackadaisical, and I suggested parents examine the eating control the adolescent's decisions know that my kids would benefit and exercise behaviors they model to about eating and physical activity, from more structured eating. their children. Specifically, parents concern for the adolescent's physical mentioned practicing what is being and mental well-being, and feelings preached to adolescents and making of personal responsibility for the ado- sure that, as a parent, you are model- Advice for Other Parents of lescent's weight issues. Parental advice ing healthful behaviors. The mother Overweight Adolescents for helping overweight adolescents in- of a 13-year-old girl said, ‘‘I think my cluded having a healthful home envi- Parents (n ¼ 24) talked about strate- recommendation would be for teens ronment, modeling healthful gies they felt were or would be helpful to see parents participating, too. If behaviors, and providing encourage- or important and offered many sug- you eat differently and you exercise ment and support to adolescents for gestions for other parents to help ado- different than they are, it doesn't positive behavior changes. lescents lose weight and improve mix.’’ A mother of a 13-year-old girl Interestingly, many of the issues eating and exercise habits. Advice said, ‘‘Parents need to be consistent participants identified are similar to is- most often noted by parents included in their own actions. That means sues faced by parents of adolescents in having a healthful home environ- don't role model to the kids McDo- general. For instance, communicating ment (n ¼ 15), role modeling health- nald's if you want them to be eating effectively about sensitive topics like ful behaviors (n ¼ 12), and providing healthy salads.’’ alcohol and drug use is a struggle support and encouragement for posi- many parents face.32 Parents inter- tive efforts (n ¼ 9). Providing support and encourage- viewed for this study may struggle ment. Several parents discussed pro- with those same issues as well, but Healthful home environment. The viding encouragement and support they were additionally concerned majority of parents discussed the im- for positive efforts toward healthful about how to discuss weight issues 504 Boutelle et al Journal of Nutrition Education and Behavior Volume 44, Number 6, 2012 with their adolescent. Most parents, behaviors. The family meal is a time weight adolescents. Through the use whether their adolescent had lost when parents have the opportunity of one-on-one interviews, rich, in- weight or not, were unsure of when to model healthful eating behaviors, depth information was gathered to bring up the subject of weight, but the frequency of family meals de- from parents about the specific issues and furthermore, how far to push creases throughout adolescence.27,28 they face on a day-to-day basis in par- the subject once the subject was In addition to the family meal enting overweight adolescents. The brought up with their adolescent. providing an opportunity to serve as interview format also allowed partici- These findings corroborate findings a role model, this is also a time for pants to expand upon responses, by Pagnini and colleagues about the parents to communicate with their which created a greater understanding challenges in having productive, adolescent as well as provide support of parental issues. Limitations of the helpful, and nonjudgmental conver- for positive behavior changes.15 study include a small, self-selected sations about weight with their chil- The current study provides initial sample size with limited diversity in dren.33 Parental advice for other data that support the idea that health- sex and ethnicity that does not fully parents of overweight adolescents ap- ful eating and physical activity behav- represent all population groups. Addi- pears to parallel and address the issues iors for adolescents could come in the tionally, some of the adolescents in faced in parenting overweight adoles- form of both ‘‘doing’’ and ‘‘talking.’’ this study had lost some weight, how- cents. For instance, advice for parents Parents can think of these 2 categories ever, the interviews did not reveal any to establish a healthful home environ- as methods for influencing their differences in parental responses be- ment and model healthful behaviors adolescent's weight. In terms of ‘‘do- tween parents of adolescents who could be helpful in addressing feelings ing,’’ parents can support their adoles- lost weight and those who did not. of responsibility for their adolescent's cent's physical activity level by Further research should expand on weight struggles and inability to con- engaging in shared activities such as these findings with larger, more di- trol all of the adolescent's decisions re- going on evening walks together, verse populations. lated to eating and activity. If parents playing active games together, and have healthful food available at home planning active family vacations; by and are modeling healthful eating and watching their children perform in IMPLICATIONS FOR exercise habits, they may be less likely various sports activities; and by pro- RESEARCH AND to feel their own actions and lifestyle viding transportation to local recrea- PRACTICE at home are to blame for their adoles- tional facilities. Parents can support cent's weight issues. Additionally, re- their adolescent in eating more Findings from this study reveal that search shows that maternal concern healthfully by providing a healthful parents of overweight and obese ado- for healthful eating is associated with home environment and modeling lescents face many issues and have both maternal and adolescent fruit healthful eating behaviors. a wealth of information to help other and vegetable consumption.24 Simi- In terms of ‘‘talking’’ about adopt- parents facing similar issues. In terms larly, parents may feel more confident ing more healthful eating and physical of practice, study findings suggest in an adolescent's decision-making activity behaviors, it is important for that it may be helpful for health care ability about healthful eating and ac- parents to remember that their adoles- providers to include family members tivity if they have done what they cent could have a negative emotional in the treatment process as well as felt was possible in their own home response (ie, sad or angry) when consider the adolescent's level of au- and modeled healthful behaviors. Re- questioned about their weight. In the tonomy and the context in which sults from the current study are also current study, and in other studies,33,34 the adolescent fits into the family similar to those of Booth and col- parents were aware of the psychosocial structure. It may be most helpful for leagues, who interviewed parents of effects of being overweight. Therefore, health care providers to operate in overweight youth and reported con- exploring other methods of addressing a nonjudgmental manner toward cerns by parents regarding the weight issues besides just focusing on both an overweight adolescent and amount of control they had over weight loss may be needed when his or her parents, as discussing weight-related decisions their chil- working with adolescents, such as weight may bring up negative emo- dren make.34 Parents felt they did being fit and physically active, or tions in both the adolescent and the have control over what food was in eating for health. Practitioners can parent. Findings from the current the home. Data from the current help facilitate positive change within study further suggest that health care study provide further support for the home environment for the whole providers should emphasize that par- quantitative findings showing the im- family instead of focusing only on the ents can set an example and model portance of parental modeling and adolescent. In addition, given the healthful behaviors both at home home availability of healthful food, issues about communication, it is and away from home. such as fruits and vegetables, in the important that practitioners recognize This study also provides a number adolescent's intake,16,18 as well as these challenges and work to support of potential research targets. Many qualitative studies with adolescents and help both parents and adolescents. parents interviewed in this study citing these factors as contributors to The current study has several struggled with effectively communi- their food choices.17 Parental provi- strengths and limitations that deserve cating with their adolescent about sion of healthful meals and modeling notation. A strength of the study is its weight issues. It is possible that fami- of healthful behaviors could assist exploration of parenting issues from lies could benefit from parenting their adolescent in engaging in these the perspective of parents of over- groups for parents of overweight Journal of Nutrition Education and Behavior Volume 44, Number 6, 2012 Boutelle et al 505 adolescents that target communica- proaches for childhood overweight: 19. MacFarlane A, Crawford D, tion techniques about weight. Parents a randomized controlled trial. JAMA. Worsley A. 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