Understanding Youths ’ Experiences in a Holistic Weight Management Program

Given elevated levels of overweight/obesity among today’s youth (Centre for Disease Control and Prevention, 2008), and associated negative physical, emotional, and psychological consequences (e.g., Faith, et al., 1997; Must & Anderson, 2003), weight control programs must be critically examined. The purpose of this study was to gain understanding of youths’ experiences in a commercially available weight management program with a holistic approach. Participants included four purposefully sampled male and female youth aged 10-18, engaged in a 16-week program. Participants engaged in a semi-structured interview exploring their experiences within the program. Results indicated youth experienced positive development in the areas of physical, psychological and social skills, and highlighted specific mechanisms by which the program facilitated this development including the holistic approach, parent and peer engagement, and the required work ethic. Youth also reported negative experiences due to lack of autonomy, not reaching weight loss goals, and low enjoyment. Practical implications and future research directions are discussed.


Introduction
Youth overweight/obesity has reached epidemic proportions, as the rates have tripled over the last thirty years (Centers for Disease Control and Prevention, 2008).More specifically, it has been reported that 34% of youth aged 12-19 years are considered overweight/obese (Ogden, Carroll, & Flegal, 2008).This is particularly concerning given the adverse physical, psychological, and emotional consequences of youth obesity.For example, obesity in youth is linked not only to negative health consequences (e.g., high blood pressure, diabetes, elevated cholesterol levels (Faith, Pietrobelli, Allison, & Heymsfield, 1997;Must & Anderson, 2003), but also psychosocial issues such as poor body image, social isolation, fewer friendships, and stigmatization by peers (e.g., Miller & Downey, 1999;Strauss, 2000;Strauss & Pollack, 2003).
Given these negative consequences, numerous obesity interventions and weight loss programs are increasingly popular.Boon and Clydesdale's (2005) review of childhood and adolescent obesity interventions found that only some programs reported moderate success.Similarly, in a study of the effectiveness of standard weight loss programs for young adults, Gokee-LaRose, et al. (2009) found that programs centered on group meetings, daily calorie and fat gram goals, gradually increasing exercise, and training in core behavior modification skills, did not meet young adults' weight control needs, and led these researchers to suggest that urgent research was needed to improve recruitment and retention of this specific population to weight loss programs.However, the majority of previously examined programs have taken place in hospital or other clinical settings such as paediatric obesity clinics (Morinder, Biguet, Mattsson, Marcus, & Larsson, 2011).Such clinical-based programs are limited both, because of their minimal success in obesity reduction (e.g., Schwartz, et al., 2007), but also because they are not readily available to the public given their affiliation with institutions and long waiting lists (Dremaine, et al., 2007).
As such, there has been recent growth in commercially available programs for youth, with many having a broader focus on lifestyle management within the family, rather than simply weight loss among individual youth.Bauer, Haines, and Neumark-Sztainer's (2009) proposed an ecological framework to develop adolescent obesity prevention strategies.This framework calls for the consideration of multiple potential influencers including families, peers, schools, other institutions, communities, and societies, when creating weight loss interventions for youth.This framework also takes into consideration potential unintended negative outcomes of obesity prevention programs, namely increases in dieting and body dissatisfaction, further stigmatization and weight-related teasing.Bauer and colleagues (2009) suggest a more integrated approach to weight management, advising that future interventions take special care to avoid negative outcomes among youth.A holistic and integrated approach also allows programs to foster positive youth development (PYD; Damon, 2004).To focus solely on physical/biological outcomes (i.e., weight loss) is to neglect a clear opportunity to foster the complete development of the young person.Programs that focus on the development of positive relationships, increasing confidence, and fostering self-esteem provide the participants with the opportunity to develop in other ways, and subsequently, can lead to a broad range of positive outcomes beyond weight loss.
A growing number of recent intervention programs for youth appear to be taking a more holistic approach.For example, Quinlan, Kolotkin, Fuemmeler, and Costanzo (2009) examined a residential weight loss camp for overweight youth that included both physical and psychosocial (e.g., body image, self-esteem, family and peer support) focused interventions.Participants experienced a significant BMI reduction, but also significant improvements in body esteem, selfesteem, self-efficacy, quality of life, anti-fat attitudes, and the importance placed on appearance.Similarly, Birch (2011) found overweight and obese youth experienced significant improvements in weight, waist circumference, body composition, blood pressure, aerobic fitness, as well as self-esteem over the course of their residential weight management camp.Further, Kitzman-Ulrich, et al. (2010) found that programs aimed at improving the entire family's physical activity (PA) and dietary behaviours led to greater improvements in youth health behaviours.
While these weight loss programs have received empirical support for their effectiveness in altering physical and psychological outcomes, there has been limited qualitative investigation of participants' experiences within such programs, a critical piece to better understanding why and how these programs may be successful.One exception is a recent study by Morinder and colleagues (2011), which examined obese adolescents' perceptions of a program at a Swedish paediatric obesity clinic through semi-structured interviews.Findings suggested adolescents' responses differed depending on the approach taken within the intervention program.When the weight loss program focused on body weight primarily through recommendations and inflexible routines, participants experienced despair and disappointment, ambivalence and uncertainty, and shame and guilt.On the other hand, when the intervention was focused on the individual, youth experienced personal empowerment, safety and relief, and acceptance and realization.Participants highlighted the importance of being able to share ideas and opinions about treatment with staff, losing weight for 'themselves rather than others', the program being flexible and adjusted to their own needs, and their personal goals matching program goals.
Given the magnitude of the overweight/obesity epidemic among adolescents, the growing popularity of alternative programs in non-paediatric settings, and the mixed findings regarding the effectiveness of these programs, it is imperative to gain greater understanding of adolescents' experiences in these programs.As such, the purpose of this study was to gain understanding of youths' experiences in a commercially available weight management program with a holistic individualized approach.

Method Context and Participants
Participants in this study were enrolled in a commercially available youth weight management program with a holistic approach in a large Canadian city.The program was set up as a 16week after school program, run out of a local community centre.The program was chosen as an appropriate context for the study, as it provided an accessible alternative to clinical and physician-based weight loss programs using a holistic approach.Specifically, the primary objectives of the program were to help overweight youth learn new health, fitness, and life skills and to transfer these skills into their everyday lives.The program was designed to incorporate family members, peers and professionals to provide a supportive environment for the participants.The program had been developed by a knowledgeable scientific advisory board that included physicians, nutritionists, kinesiologists, and psychology professionals, and was administered by trained nutrition and exercise professionals.
Participants included four overweight or obese (BMI >25 kg/m 2 ) male and female youth ages 10-18 years, enrolled in the program during winter and spring of 2010, purposefully sampled for maximum diversity (Patton, 2002).Participants attended two to three 90-minute sessions per week, which involved customized PA sessions, individual and group workshops, and lifestyle education for the family.Participants' physical activity sessions took place in two locations within the community centre: the community centre's main fitness room, as well as in a private room among only program peers.Sample activities within PA sessions included non-competitive games, group circuits, and individually tailored resistance training and aerobic exercises.Nutrition and lifestyle management workshops took place in a private room within the community centre; they focused in areas such as snacking, serving sizes, food label awareness, body image, confidence, and empowerment.The family was encouraged to attend workshops to facilitate youths' learning of healthy eating habits, implementation of PA routines, and integration of positive life skills into daily routines.

Data Collection and Analysis
Upon completion of the 16-week program, participants took part in an interview to discuss their experiences in the weight management program.The interview guide was developed following extensive literature reviews (i.e., paediatric weight management, positive youth development).Key questions addressed changes in behaviours and personal development throughout the course of the program; probing questions focused in areas such as confidence, competence, social interactions, motivation, and engagement.Sample questions included: "Have you noticed any (positive/negative) changes in your (physical ability/lifestyle behaviours/physical skills?)"Interviews were administered by a research assistant trained in qualitative research methods, and lasted 15 to 35 minutes.Ethics approval was attained by the affiliated university's Human Participants Review Committee (HPRC) and conformed to the standards of the Canadian Tri-Council Research Ethics Board.Informed consent was acquired by all participants involved in the study.Interviews were transcribed verbatim and analysed through content analysis, following previously established guidelines (Côté, Salmela, Baria, & Russell, 1993;Patton, 2002;Tesch, 1990).Transcripts were read and re-read extensively with meaning units being highlighted and 'tagged' with appropriate terms.Meaning units were in turn grouped into themes, and themes organized into categories.

Results
Findings emerged from the data in three categories: a) youths' positive skills developed through the program b) mechanisms facilitating youths' positive development through the program, and c) youths' negative experiences within the program.Table 1 provides an overview of categories and respective themes.Participants discussed several positive changes in behaviour that they attributed to their involvement in the program.In particular, they spoke about being more physically capable to do everyday activities due to improvements in strength and endurance.These improvements were also noticeable when measured against their peers.As one participant commented, "I guess I'm not so tired all the time and when I do like run or whatever, I'm not behind or anything like that.I'm like in the front now."Further, participants suggested their involvement in the program led to an interest in engaging in other physicallybased extracurricular activities at school.One participant commented: After coming here I've been joining my school's teams and trying out for different things.I didn't used to do this cause I thought I'd never make any team.Now coaches are usually encouraging me.Like they said to me one time, "You're gonna be on the basketball team" and all that (…) It's really a life changing experience for me.
Psychological skills.Participants also spoke of increased confidence and self-esteem, often citing that that felt more comfortable in their clothes and with their body.In addition, some participants spoke of improved stress management and anxiety control skills that they gained as a result of being involved in the program.As one participant outlined, In particular, participants suggested that they learned to support their peers, as they were eager to reciprocate the support they received.Physical activity and health education focus.Participants spoke of the value of both the PA and health education components of the program.In particular, they discussed how they now possessed a level of knowledge about PA and healthy nutrition that they did not possess prior to the start of the program, and how this knowledge led them to change their behaviours.
Participants spoke positively about the program's hands-on engagement in PA, where they were introduced to new activities in a supportive non-threatening environment, while being taught and encouraged how to take a healthy balanced approach to PA.They spoke of how this approach led to positive changes in the areas of sports (e.g.basketball), strength (e.g.sit-ups and push-ups), and endurance (e.g.ability to run for longer periods of time).Further, participants detailed how they now chose to eat healthier meals, comprised of smaller portions, with improved balance (i.e., carbohydrates, proteins, and fats; fruits, vegetables, grains, etc.)

Youths' Negative Experiences within the Program
Instructor directed physical activity.While participants appreciated the hands-on PA component of the weight management program, they discussed how they wished the program were more adaptable to their specific needs and interests, and how they wanted to be more involved in making PA choices within their program.Participants suggested they felt restricted in the activities instructors permitted them to engage in and they would enjoy the PA more, if they had greater say in their specific activities, particularly as they gained more knowledge.Specifically, they expressed frustrated of using the cardio machines (e.g., elliptical, treadmill), and would like to engage in more group activities (e.g., spinning classes, group games) and individualized programs (e.g., weight resistant exercises).
Parent control.While two participants spoke of the importance of parent support, the other two participants suggested that parents were too involved in their weight management, playing more of a controlling role.In particular, they discussed how it was a parent's decision for them to join the program, how they had resisted enrolling, and how this tension persisted throughout the program.
Um, [my mother] just like said, "Oh, maybe you need to like, lose some weight or like you're not going to be healthy.You're not eating proper foods -like, too big portion sizes and whatever.And I heard about this program and I really want you to do it."And then even if I said, "Oh, no, I don't want to do it," she would still be like, "Well, I'm going to make you do it anyway."So whatever.
[Sigh] Sometimes I may have missed a few classes cause I might have given her a hard time not wanting to come.
Not meeting weight loss goals.Participants also spoke of the challenge of accepting the long period of time required to achieve results, particularly weight loss goals.As one participant expressed, I'm a little more confident with like clothes I wear and stuff.But I mean, like I said, I'm not quite there yet so I still haven't bought any really good clothes for myself or anything like that.But, I will soon, like, it's just a matter of time.It takes a lot of time, but it's a matter of time (…) Yeah, so far I've been seeing some good changes.I mean, sometimes I'm a little disappointed.Like say I lost 1 inch instead of 2 inches or something like that.
Not always enjoyable.Likely due to some of the negative experiences outlined above, some participants suggested that involvement in the program was not always enjoyable.One participant outlined, I feel like I need to do it.I don't enjoy it that much.It's not something that I would do if I was bored.I would not be like, "Oh! Let's do some exercise!"type of thing (…) I'll do it because I know I need it but there's nothing that I really really like about exercising.

Discussion and Conclusion
The purpose of this study was to gain understanding of youths' experiences in a commercially available weight management program with a holistic approach.Findings emerged in three key categories: a) youths' positive skills developed through the program b) mechanisms facilitating youths' positive development through the program, and c) youths' negative experiences within the program.

Facilitating Positive Developmental Experiences
This was the first study to directly highlight the potential of a weight management program to facilitate positive development among youth in the areas of psychological and social skills.
While numerous studies have examined weight management programs' effectiveness by assessing individuals' physical changes (e.g., anthropometric measures), this study highlights the potential of such programs to also facilitate positive change in broader areas of development.Findings of this study also highlight specific mechanisms by which this development was facilitated, as participants outlined the importance of peer support, parent support, the program's holistic focus, and the hard work required to complete the program.
Engagement of parents and peers.Parents' involvement in their children's personal development appears to be an important contributor to youths' positive developmental experiences.In this program, parents and youth were educated together about healthy PA routines and eating habits, facilitating knowledge throughout the entire family unit, something that may be critical for youth to succeed in weight management programs.It appears that participants garnered positive developmental experiences due to parents attending sessions, 'buying in,' to the program, and experiencing the weight management journey alongside them.These findings build on Kitzman-Ulrich, et al.'s work (2010) by providing additional understanding of the means by which the family's involvement in the weight management program can lead to greater improvements in youths' health behaviours.Findings also emphasize the importance of peers to motivate, support, and help maintain healthy behaviour change.While few studies have specifically investigated the role of peers in clinical weight management settings, current findings align with previous work by Smith (1997;1999) in PA and sport settings, highlighting that youth who perceive positive relationships with peers report having higher PA motivation, more positive feelings towards being physically active, and a higher sense of physical self-worth.
Holistic approach.Participants consistently emphasized that one of the strengths of the program was its focus on both PA engagement and health education.This holistic approach can be seen in an increasing number of clinical and commercially available weight management programs.For example, Bauer and colleagues' ( 2009) ecological framework emphasized that weight-related issues be addressed taking a holistic approach, focusing on individual factors (e.g., eating behaviours), familial factors (e.g., family meal plans), peer influences (e.g., peer dieting norms), school and institutional factors, community factors, and societal factors.The holistic approach taken in weight management camps has also been found to be successful (e.g., Birch, 2011;Quinlan, et al., 2009).The results of the present study indicate that the physical and psychological benefits of these camps may also be possible in non-residential settings.
Hard work.The importance of hard work was highlighted by all participants in the present study.Larson (2000) first emphasized the importance of youth demonstrating effort directed towards a challenging goal in order to develop initiative (in addition to motivation and focused attention).

Turning Negative Experiences into Positive Development
While youth discussed numerous positive developmental experiences, and outlined how these experiences were facilitated, they also had negative experiences within their program.In particular, findings suggested the program may not have offered sufficient autonomy to participants, given the key role instructors played in directing PA, and the controlling role that parents sometimes played in youths' program involvement.Further, participants suggested they experienced frustration in not meeting weight loss goals; collectively, these experiences led youth to not always enjoy their program involvement.
Youth autonomy.While our results highlight the value of parents being engaged in the weight management program, our findings also suggest the importance of youth having autonomy to initiate and follow through in their program involvement.Past research suggests individuals are most successful engaging in and maintaining healthy lifestyle changes if they are internally invested to change, independent of external sources' advice to alter behaviours (e.g., Ryan & Deci, 2000).In the present study, two participants felt obligated to enroll in the program due to parent pressures.These individuals suggested they did not want to participate, and reported giving their parents a hard time surrounding attendance.When considering youths' optimal development, being able to make one's own choices, rather than being told what to do allows youth to feel in control of their lives (Damon, 2004).Rather than requiring their children to participate in the program, open parent-child discussions regarding weight loss programs and the dangers of being overweight/obese may be appropriate.This dialogue could allow the child to express their reservations as to why they may be resisting program participation and may help alleviate future parent-child conflicts surrounding the program.
It appears that program instructors may also have contributed to participants feeling a lack of autonomy within the program, as participants suggested that the program used a 'one size fits all' approach on some occasions.Consistent with Morinder et al.'s, (2011) findings, youth in the present study clearly valued sharing thoughts and ideas throughout the program, and stressed the importance of the program being catered to their individual needs and interests.Opportunities for autonomy are consistently associated with the most intrinsic forms of motivation for behaviour change (Deci & Ryan, 2000), making such opportunities particularly critical for overweight/obese youth who at-risk of poor health.
Weight loss goals.Findings highlight the struggles participants experienced due to weight loss occurring very slowly.Given recommended healthy weight loss is approximately 1-2 pounds per week (Fontaine et al., 1999), such struggles are likely present in many weight management programs.As such, it is imperative that future programs focus on strategies to prepare for and/or avoid frustrations of gradual weight loss.A goal-setting program emphasizing process goals (i.e., focus on the actions that the individual must engage in during the process of weight loss), versus outcome goals (i.e., the actual weight lost; Weinberg & Gould, 2003) would be ideal in maintaining participation.Further, focussing on alternative goals (e.g., increased energy and stamina, maintaining a consistency within the program) may also ensure youth are able to see continued progress towards their goal, and do not experience a sense of discouragement due to stagnancy in achieving their goals.Setting goals beyond weight loss was also reported as important by Morinder et al., (2011), as participants perceived weight loss to be the primary program goal, which was not always in accordance with their own personal goals.Additionally, programs should inform participants from the onset that gradual steady weight loss is ideal, so youth are not disappointed by "slow" weight loss.

Conclusions and Future Research Directions
This study advances our understanding of youths' experience within a commercially available weight management program with a holistic approach.Findings may be of interest to health promotion specialists, physical education teachers, policy makers, and other health professionals in community, school, and clinical programs.Findings highlight the importance of incorporating both a PA and health education component to the weight management program, having participants contribute to individually tailored programs, and developing and maintaining realistic goals that are not limited to simply losing weight.Additionally, the results of this study stress the importance engaging the broader family unit in the weight management program, and assuring peer support networks within programs.
While the present study provides a solid starting point for understanding youths' experiences, much more research is necessary to develop optimal programs that are both effective in facilitating appropriate weight management and other positive developmental experiences and outcomes among youth.This study explored the experiences of four purposefully sampled youth who differed in age, and gender; however, greater research among specific populations in additional program types is necessary.Specifically, examination of potential differences between sexes' and age groups' experiences in weight management programs would be worthwhile.Future studies may also be well advised to qualitatively investigate the perceptions of parents regarding their children's experiences in weight management programs, as parents may provide additional insight into how youth experience their weight loss, maintain motivation, develop work ethic, and potentially come to enjoy their experiences.
Yeah, I've been happier since I've started [the program].I'm in a lot better shape (…) I'm a little bit more confident with like self-esteem and everything (…) Just cause my school's night school and I have to deal with unbelievable stress and everything.I find that I get stressed out, and really had like anxiety.I used to snap really easily but now I guess it's a little better cause like when you run and stuff, it releases all that stuff, you know (…), Social skills.Participants discussed development of their social skills through the program.

Table 1
Summary of Results: Categories and Themes As stated by one participant, "I like [the] group because you can learn like what everybody's going through.You can kind of connect [to each other]."Additionally, participants reported that they felt more comfortable in social situations and had developed new friendships at school since being involved in the program.Mechanisms Facilitating Youths' Positive Development Through the Program Peer support.Participants consistently highlighted the importance of peer support in contributing to the success of the program.Specifically, they discussed how the group atmosphere within the program made the exercising experience more manageable and provided a social network of support.As one participant stated "Well, since I came here, I thought I'd get a little bit nervous around other kids.But actually, they helped me to succeed."Another said, I mean, you meet a lot of cool people and like, I mean, sometimes exercising is no fun but you know if you have a whole bunch of people (…) I think it's better to do it like a program like this instead of by yourself (…) 'cause if you do it by yourself, you're like, 'Oh, I'll do it next time.Next time I'll do better or push myself harder,' but you never really do.
work.Participants were all in agreement that this particular program required them to work hard.As one participant said, "I would probably[recommend]to come to [this program] but only if they're willing to work hard and listen to the coaches and stuff; but not if they just want to slack off and just do a little bit of work."Parents'support.Two participants discussed the critical role of their parents' support throughout the program, from enrollment to conclusion.They highlighted the importance of discussing their enrolment in the program with their parents, and communicating throughout the program with regard to new knowledge, behaviour changes, and ongoing weight management.One participant said, "Well, I said to my mom 'I have to try this in order for me to achieve what I want to achieve [my goal to get slimmer].I have to try this."