One-on-one lifestyle coaching for managing adolescent obesity: Findings from a pilot, randomized controlled trial in a real-world, clinical setting.
ABSTRACT Interventions for obese adolescents in real-world, clinical settings need to be evaluated because most weight management care occurs in this context.
To determine whether a lifestyle intervention that includes motivational interviewing and cognitive behavioural therapy (Health Initiatives Program [HIP]) leads to weight management that is superior to a similar lifestyle intervention (Youth Lifestyle Program [YLP]) that does not include these techniques; and to determine whether the HIP and YLP interventions are superior to a wait list control (WLC) group.
Obese adolescents were randomly assigned to a YLP (n=15), HIP (n=17) or WLC (n=14) group. The YLP and HIP were 16-session, one-on-one interventions. The primary outcome was the percentage change of body mass index z-score.
Completers-only analyses revealed 3.9% (YLP) and 6.5% (HIP) decreases in the percentage change of body mass index z-score compared with a 0.8% (WLC) increase (P<0.001). Levels of attrition did not differ among groups, but were relatively high (approximately 20% to 40%).
Lifestyle interventions delivered in a real-world, clinical setting led to short-term improvements in the obesity status of adolescents.
- SourceAvailable from: Sinéad Patricia Dufour[Show abstract] [Hide abstract]
ABSTRACT: Abstract Purpose: To evaluate a program in support of chronic disease self-management (CDSM) that is founded on a health coaching (HC) approach, includes supervised exercise and mindfulness-based stress reduction components and is delivered within a private practice physiotherapy setting. Methods: An explanatory mixed method design, framed by theory-based program evaluation, was employed to evaluate an eight-week group-based program. Standardized self-rated and performance measures were evaluated pre- and post intervention. Additionally, participant focus groups were conducted following the intervention period. An inductive thematic approach was undertaken to analyze the qualitative data. Findings: Seventeen participants (N = 17) completed the study. Improvements were seen in both self-report and performance outcomes. Participants explained how and why they felt the program was beneficial. Six themes were generated: (1) group dynamic; (2) learning versus doing; (3) holism and comprehensive care; (4) self-efficacy and empowerment; (5) previous solutions versus new management strategies; and (6) healthcare provider support. Conclusions: This study established that a group program in support of CDSM founded on a HC approach demonstrated potential value from participants as well as favorable outcomes. A pragmatic randomized control trial is required to determine efficacy of this intervention.Physiotherapy Theory and Practice 07/2014;
- [Show abstract] [Hide abstract]
ABSTRACT: Severe obesity (SO) in pediatrics has become increasing prevalent in recent decades.The objective of our study was to examine differences in demographic, anthropometric, cardiometabolic, and lifestyle variables in children and youth with SO versus their less overweight/obese (OW/OB) peers.BMC Pediatrics 06/2014; 14(1):154. · 1.92 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: There is an urgent need to identify effective weight management interventions in real-world, clinical settings to improve the health of children with obesity. To determine the impact of individualized, interdisciplinary care on the weight status of children with obesity; to assess the relationship between clinical interactions and change in participants' weight status; and to document the degree of program attrition. A retrospective medical record review of clinical and administrative data from a paediatric weight management clinic in Edmonton, Alberta, was performed, which included data from a group of five- to 18-year-olds (body mass index [BMI] ≥85th percentile) collected from 2008 to 2012. Demographic, anthropometric and attendance data were retrieved from baseline and follow-up at three-, seven- and 11-month timepoints. The primary outcomes were participants' BMI z-score and change in BMI z-score over time. Data from 165 individuals were included. Among those with follow-up anthropometric data, weight stabilization occurred at three (n=127) and seven months (n=84). For individuals with follow-up anthropometric data at 11 months (n=44), BMI z-score tended to decrease over time (-0.05±0.12 units; P=0.06). Program attrition increased over time (23%, 49% and 73% at three-, seven- and 11-month follow-ups, respectively). Between presentation and three-month follow-up, there was an inverse relationship between the number of clinical appointments attended and change in BMI z-score (r= -0.18; P=0.04), an association that became nonsignificant at seven and 11 months (both P>0.05). An individualized, interdisciplinary weight management intervention led to weight stabilization and a modest weight reduction in children with obesity. Strategies to minimize program attrition are needed to optimize family engagement in care and success in managing paediatric obesity.Paediatrics & child health 12/2013; 18(10):e59-63. · 1.55 Impact Factor
Paediatr Child Health Vol 16 No 6 June/July 2011 345
One-on-one lifestyle coaching for managing adolescent
obesity: Findings from a pilot, randomized controlled
trial in a real-world, clinical setting
Geoff DC Ball PhD RD1,2, Kelly A Mackenzie-Rife MSc CEP1, Mandi S Newton PhD RN2, Christina A Alloway MSc2,
Julie M Slack MSc RD3, Ronald C Plotnikoff PhD4,5, Michael I Goran PhD6
1Pediatric Centre for Weight and Health, Stollery Children’s Hospital; 2Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta,
Edmonton, Alberta; 3Northwestern Health Unit, Atikokan, Ontario; 4School of Education, The University of Newcastle, Callaghan, New South
Wales, Australia; 5Faculty of Physical Education and Recreation, School of Public Health, University of Alberta, Edmonton, Alberta; 6Department of
Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
Correspondence: Dr Geoff DC Ball, Unit 8B, Pediatric Centre for Weight and Health, 11111 Jasper Avenue, Edmonton General Continuing Care
Centre, Edmonton, Alberta T5K 0L4. Telephone 780-342-8465, fax 780-342-8464, e-mail firstname.lastname@example.org
Accepted for publication July 31, 2010
several chronic diseases. Overweight and obese children referred
for weight management often exhibit suboptimal lifestyle behav-
iours (3) – a finding that highlights the potential for interventions
to promote healthier habits. These observations, along with recent
clinical practice guidelines (4) and best practice recommendations
(5), underscore the importance of healthy lifestyle behaviours as
the cornerstone of paediatric weight management. Even in situa-
tions for which more intensive therapy may be indicated, nutri-
tion, physical activity and behavioural counselling remain
foundational strategies (6,7).
Evidence supporting the successful treatment of paediatric
obesity is primarily derived from group-based interventions,
pproximately two million Canadian boys and girls are over-
weight or obese (1,2), which places them at increased risk for
which tend to be more efficacious (8) and cost effective (9),
and reduce attrition (10) versus one-on-one care. Alternately,
one-on-one care is more feasible, appropriate (in some situations)
and common in many Canadian paediatric weight management
clinics (11). A key limitation of the aforementioned research is
that most studies included community-based volunteers – a situa-
tion that differs for many paediatricians who refer obese boys and
girls to multidisciplinary weight management clinics. Recently,
the Canadian Institutes of Health Research (CIHR) emphasized
the value of integrating research into practice-based settings as a
way to enhance health services for Canadians (12). We believe
that offering one-on-one interventions in clinics that provide
paediatric weight management care and conduct applied research
in real-world environments can inform health service delivery
©2011 Pulsus Group Inc. All rights reserved
GDC Ball, KA Mackenzie-Rife, MS Newton, et al. One-on-one
lifestyle coaching for managing adolescent obesity: Findings
from a pilot, randomized controlled trial in a real-world, clinical
setting. Paediatr Child Health 2011;16(6):345-350.
BACKGROUND: Interventions for obese adolescents in real-world,
clinical settings need to be evaluated because most weight manage-
ment care occurs in this context.
OBJECTIVES: To determine whether a lifestyle intervention that
includes motivational interviewing and cognitive behavioural therapy
(Health Initiatives Program [HIP]) leads to weight management that
is superior to a similar lifestyle intervention (Youth Lifestyle Program
[YLP]) that does not include these techniques; and to determine
whether the HIP and YLP interventions are superior to a wait list
control (WLC) group.
METHODS: Obese adolescents were randomly assigned to a YLP
(n=15), HIP (n=17) or WLC (n=14) group. The YLP and HIP were
16-session, one-on-one interventions. The primary outcome was the
percentage change of body mass index z-score.
RESULTS: Completers-only analyses revealed 3.9% (YLP) and 6.5%
(HIP) decreases in the percentage change of body mass index z-score
compared with a 0.8% (WLC) increase (P<0.001). Levels of attrition
did not differ among groups, but were relatively high (approximately
20% to 40%).
CONCLUSION: Lifestyle interventions delivered in a real-world,
clinical setting led to short-term improvements in the obesity status of
Key Words: Adolescent; Intervention; Obesity
L’accompagnement individualisé du mode de vie
pour prendre en charge l’obésité chez les
adolescents : les observations d’un essai pilote
aléatoire et contrôlé en milieu clinique réel
HISTORIQUE : Il faut évaluer les interventions auprès des adolescents
obèses en milieu clinique réel parce que la plupart des soins de prise en
charge de l’obésité se produisent dans ce contexte.
OBJECTIFS : Déterminer si une intervention sur le mode de vie, incluant
une entrevue motivationnelle et une thérapie cognitivocomportementale
(Health Initiatives Program [HIP]), favorise une gestion du poids plus
efficace qu’une intervention similaire sur le mode de vie (Youth
Lifestyle Program [YLP]) qui exclut ces techniques; et déterminer si les
interventions HIP et YLP sont plus efficaces qu’un groupe témoin sur
une liste d’attente (TLA).
MÉTHODOLOGIE : Les adolescents obèses ont été répartis au hasard
entre un groupe d’YLP (n=15), de HIP (n=17) ou de TLA (n=14). Les
groupes d’YLP et de HIP ont reçu 16 séances d’interventions
individualisées. L’issue primaire était le changement en pourcentage de
l’écart réduit d’indice de masse corporelle.
RÉSULTATS : Les analyses de ceux qui avaient terminé l’étude ont
révélé des diminutions de 3,9 % (YLP) et de 6,5 % (HIP) du changement
en pourcentage de l’écart réduit d’indice de masse corporelle, par rapport
à une augmentation de 0,8 % (TLA) (P<0,001). Les taux d’attrition,
relativement élevés, demeuraient les mêmes entre les groupes (environ
20 % à 40 %).
CONCLUSION : Les interventions sur le mode de vie offertes en milieu
clinique réel entraînent une amélioration à court terme de l’état d’obésité
Ball et al
Paediatr Child Health Vol 16 No 6 June/July 2011346
in Canada. Because there are a limited number of evaluations of
one-on-one weight management interventions for adolescents,
other areas of intervention research can provide guidance.
The Diabetes Prevention Program (DPP ), a multicentre
clinical trial designed to prevent type 2 diabetes in adults, demon-
strated that a lifestyle behavioural intervention delivered primarily
through one-on-one counselling delays the onset of type 2 diabetes
through weight management and behavioural changes (13,14). A
developmentally appropriate version of the intervention may be well
received by obese adolescents; creating an intervention that includes
personalized goal setting and problem solving would also align with
current recommendations. Accordingly, client-centred counselling
approaches, such as motivational interviewing (15) and cognitive
behavioural therapy (16), have become increasingly popular in obes-
ity research (17,18). Evidence supporting motivational interviewing
and cognitive behavioural therapy in weight management is pre-
dominantly adult oriented; however, the principles underlying these
approaches (ie, addressing ambivalence, and increasing awareness of
thoughts and feelings regarding lifestyle habits) are well suited to
adolescents given their increasing capacity for introspection. The
purpose of the present pilot study was to use the DPP as a starting
point to develop two alternative treatment models (discussed below)
for obese adolescents that were compared with a wait list control
(WLC) group. We hypothesized that a lifestyle intervention that
includes motivational interviewing and cognitive behavioural ther-
apy would lead to superior weight management versus a similar life-
style intervention that does not include these counselling techniques.
We also hypothesized that both interventions would be superior to a
WLC group. Because the present research was conducted in a multi-
disciplinary paediatric weight management clinic, we also docu-
mented process-related outcomes including treatment initiation,
attrition, feasibility and acceptability.
The present pilot, randomized controlled trial was conducted in
a weight management clinic in Edmonton, Alberta. Participants
were enrolled in the study from January 2006 to September 2007,
and were eligible if they were 13 to 17 years of age and possessed
a body mass index (BMI) at the 85th percentile or greater (19).
Preintervention testing occurred over two separate days (10 to
14 days apart) within four weeks of starting the treatment phase,
which lasted 16 to 20 weeks. Post intervention testing was identical
to the preintervention procedures; all measurements were completed
within four weeks of ending the treatment phase. No follow-up
data beyond the postintervention time point were presented. The
primary outcome variable for the study was the percentage change
(%∆) in BMI z-score, and sample size was based on previous inter-
vention studies with similar study designs and outcomes (20,21).
The aim was to enrol 54 participants (n=18 per group). Several sec-
ondary outcome variables were also measured including anthropom-
etry (body weight, BMI, BMI percentile and waist circumference
[WC]), lifestyle-related behaviours (dietary intake, physical activity
and aerobic fitness) and metabolic risk factors (blood cholesterol,
insulin, glucose and blood pressure). Before beginning preinterven-
tion testing, a child psychiatrist or psychologist completed 45 min to
60 min standardized assessments to gauge whether any psychosocial
or familial factors precluded potential participants from study inclu-
sion. Based on these assessments, all boys and girls were deemed
appropriate. The study biostatistician (CAA), who had no contact
with either participants or intervention providers, performed all
randomization and intervention allocation tasks. The research team
and participants (but not intervention providers) were blinded
to group allocation. Parents and adolescents completed informed
consent and assent processes, respectively, and the University of
Alberta/Alberta Health Services Health Research Ethics Board
(Edmonton) approved the research.
Demographic data were provided by parental report. Height and
weight were measured; BMI, BMI percentile and BMI z-score were
subsequently calculated. WC was measured at the narrowest point
between the xyphoid process and the iliac crest. Dietary intake was
measured using a four-day food record (three weekdays plus
one weekend day) and data were subsequently analyzed using a
nutrition software program. Pedometers assessed physical activity
over the same four-day period, and these data were supplemented
by a seven-day physical activity recall survey that assessed
moderate-to-vigorous physical activity (22). Information regarding
sedentary activity (screen time) was also retrieved. Aerobic fitness
was determined on a treadmill using a walking protocol (23). A
fasting blood sample was collected to measure total cholesterol,
high-density lipoprotein cholesterol, low-density lipoprotein chol-
esterol, triglycerides, insulin and glucose. Systolic and diastolic
blood pressure were measured manually.
Participants were randomly assigned to one of three intervention
groups: Youth Lifestyle Program (YLP), Healthy Initiatives Program
(HIP) or WLC. Key similarities and differences between YLP and
HIP interventions are summarized in Table 1. Similar to the DPP
(13), both interventions were 16 to 20 weeks in duration, and
Overview of the similarities and differences between weight management interventions for obese adolescents: The Youth
lifestyle Program (YlP) versus the Healthy Initiatives Program (HIP)
Frequency of delivery: Weekly
Mode of delivery: One-on-one coaching
Number of sessions: 16
Intervention length: 16–20 weeks
Individual session length: 45–60 min
Intervention structure: Manualized; includes manuals for both leaders and adolescents
Intervention development: Evidence-informed, multidisciplinary team approach;
curriculum reviewed by external experts and adapted based on external expert review
Intervention providers: Clinicians with expertise in nutrition, physical activity/exercise
physiology and/or mental health
Weekly case conferences to discuss participants and intervention-related issues: Yes
Parent participation: Yes
Lifestyle behaviour goals
YLP: Reduce dietary fat intake, increase physical activity time
HIP: Increase vegetable and fruit intake, increase steps/day
YLP: Focus on education, self-monitoring and goal setting
HIP: Focus on education, self-monitoring and goal setting plus
motivational interviewing and behavioural and cognitive change
Managing adolescent obesity
Paediatr Child Health Vol 16 No 6 June/July 2011 347
included content regarding nutrition, physical activity, sedentary
activity, self-esteem and relapse prevention; they also included weekly
case conferences for clinicians, pedometers for physical activity track-
ing and self-monitoring strategies. All sessions included (sequentially)
rapport building, review of the previous session (content, lifestyle
behaviour monitoring and goal setting), new curriculum content, ses-
sion summary, and goal setting and planning for the upcoming week.
The critical difference was that, unlike YLP, HIP included counsel-
ling and communication strategies consistent with motivational
interviewing and cognitive behavioural therapy, which catered to
adolescents’ motivations and readiness to change. This enabled clin-
icians to adapt communication and educational strategies based on
participants’ motivation and stage of change. Leaders encouraged
adolescents to discuss their thoughts and feelings regarding the HIP
lifestyle goals to help teenagers set personal goals and address factors
that could enable or impede cognitive and behavioural changes.
Given concerns regarding unhealthy weight management practices
during adolescence (24), both YLP and HIP did not include prescript-
ive energy intake or expenditure goals. Others have referred to similar
lifestyle behavioural interventions as ‘nondiet’ because they promote
the health benefits of lifestyle behaviour changes (25).
The curricula for YLP and HIP were developed by a multidisci-
plinary team. An external review panel with expertise in obesity
and intervention development critiqued the interventions, and
modifications were made based on their feedback before intervention
delivery. Participants received intervention manuals that included
age-appropriate information and educational resources. Interventions
were delivered by health professionals (RD and RN) who completed
two days of training that included both theoretical and practical
aspects of motivational interviewing, cognitive behavioural therapy
and behaviour change principles. Participants randomly assigned to
the WLC group attended a single one-on-one counselling session and
received educational materials (26,27). At the end of the interven-
tion period, individuals in the WLC group were offered the choice of
participating in either the YLP or HIP intervention.
Parental involvement is recommended when treating paediat-
ric obesity (4,28), but the extent to which parents should be
included is unclear. YLP and HIP were designed to capitalize on
adolescents’ independence by focusing curriculum content and
coaching strategies on the adolescents themselves. Parents of ado-
lescents in YLP and HIP were invited to attend three parent-only
sessions to learn about how they could support their teenagers. No
parent-directed intervention was delivered to the WLC group.
Baseline differences between those who did (completers) and did
not (noncompleters) attend postintervention measurements were
explored using independent samples t tests. Intervention groups were
compared pre-to-postintervention according to the %∆ in anthropo-
metric, behavioural and metabolic risk factor variables using one-way
ANOVA with Bonferroni post hoc comparisons; if assumptions for
normality were not satisfied, comparisons were conducted using the
nonparametric Kruskal-Wallis test with Mann-Whitney U test post
hoc comparisons. Completers-only and intention-to-treat analyses
were conducted. Covariate analyses were used to control for potential
group differences (ie, age) at baseline. Group differences in propor-
tions were examined using the c2 statistic. Differences between groups
were considered to be significant at P<0.05. Analyses were performed
using SPSS version 14.0 (IBM Corporation, USA).
As shown in Figure 1, of the 98 possible study participants, 46 pro-
gressed through the enrollment steps to complete preintervention
testing before group allocation. The main issue that limited the
study sample size was the decision by many families (n=39) to not
follow up after being referred for weight management. The recruit-
ment goal (n=18 per group) could not be achieved because of
logistical issues and resource limitations.
The demographic characteristics of adolescents are presented
in Table 2. All participants were from middle- to high- income
Figure 1) Participant flow through the study stages
Physician Referrals / Eligible for Study
n = 98
n = 59
Attended Screening Visit
n = 53
n = 47
n = 46
n = 17
n = 15
n = 14
n = 30
n = 39 declined
n = 6 not interested
n = 4 not eligible
n = 2 declined
n = 1 consent not provided
n = 16 withdrew
n = 10
n = 9
n = 11
• HIP (Healthy Initiatives Program)
• YLP (Youth Lifestyle Program)
• WLC (Wait List Control)
Demographic characteristics of the study groups at baseline
HIP versus WlC YlP versus WlC
YlP versus HIP
Sex, male:female, n
Ethnicity, Caucasian:non-Caucasian, n
Family history of type 2 diabetes, yes:no, n
Data presented as mean ± SD unless otherwise indicated. *P<0.05. HIP Healthy Initiatives Program; WLC Wait List Control; YLP Youth Lifestyle Program
Ball et al
Paediatr Child Health Vol 16 No 6 June/July 2011348
families. The YLP group was older than the HIP (by 1.6 years;
P=0.002) and WLC (by 1.4 years; P=0.01) groups, and more
sexually mature than the HIP group (P=0.01). Baseline dif-
ferences between intervention completers (n=30) and non-
completers (n=16) were examined. Compared with completers,
noncompleters had higher low-density lipoprotein cholesterol
levels (2.23±0.7 mmol/L versus 2.80±0.44 mmol/L, respectively;
P=0.006). No other group differences were significant.
Attrition timing varied within each group, but did not differ
between groups (Table 3). While approximately 40% of partici-
pants dropped out of YLP and HIP, completers in both groups had
a high degree of participation; all 16 sessions were attended by
15 of 19 participants, and at least 14 sessions were attended by
18 of 19 adolescents. Parental attendance at the group sessions did
not differ between groups.
Based on completers-only analyses, the pattern of %∆ of
BMI z-score was similar to the changes for body weight, BMI
and BMI percentile; these indexes improved in the YLP and
HIP groups only (Table 4). Although the %∆ in WC did not
achieve significance, changes were in the expected direction.
Aside from group differences in the %∆ of aerobic fitness (YLP
and HIP greater than WLC), significant differences in lifestyle
behaviours and metabolic risk factors did not emerge before or
after comparisons were adjusted for covariates. However, the
%∆ in steps/day approached significance with YLP and HIP
greater than WLC (P=0.07).
Intention-to-treat analyses showed more conservative group
differences, with significant main effects for the %∆ of BMI z-score
(F=3.8, P=0.03) and %∆ of BMI (F=6.3, P=0.004) only. Post hoc
analyses revealed that WLC increased the %∆ of BMI z-score
(0.65±1.76) versus HIP (–3.81±6.55). Although YLP decreased in
the expected direction (–2.33±3.45), YLP and WLC were not dif-
ferent in the %∆ of BMI z-score (P=0.2). WLC also increased the
%∆ of BMI (1.6±2.3), while YLP (–1.2±3.1) and HIP (–1.9±2.9)
decreased. Aerobic fitness was no longer different between groups
when intention-to-treat analyses were completed. Similar to the
analyses for the completers- only group, lifestyle behaviours and
metabolic risk factors did not differ between groups.
Several multidisciplinary clinics have been established in Canada
in recent years to provide paediatric weight management care
(11). This trend highlights the importance of deriving evidence
from real-world clinical settings because most of what we know
regarding paediatric weight management is based on efficacy stud-
ies with community-based volunteers (28) and because individuals
referred for weight management tend to be less healthy than their
nonclinical peers (29). Findings from the present pilot study dem-
onstrate that challenges such as low participation and high
anthropometric variables at preintervention and postintervention, and the percentage change from pre-to-postintervention
for completers only
PreinterventionPostinterventionPercentage changeFor trend YlP vs HIPHIP vs WlC YlP vs WlC
Waist circumference, cm
Data presented as mean (95% CI). Group comparisons for height, weight, body mass index (BMI) and waist circumference are adjusted for age; BMI percentile and
BMI z-score variables are corrected for age and sex. HIP Healthy Initiatives Program; vs Versus; WLC Wait List Control; YLP Youth Lifestyle Program
168.4 (163.3 to 173.6)
167.5 (162.7 to 172.4)
169.3 (166.0 to 172.7)
169.3 (163.7 to 174.9)
169.3 (164.4 to 174.3)
170.4 (166.8 to 174.0)
0.5 (0.1 to 0.9)
1.1 (0.6 to 1.6)
0.6 (0.2 to 1.1)
104.4 (89.5 to 119.3)
98.1 (86.4 to 109.8)
106.4 (96.2 to 116.7)
103.3 (88.4 to 118.2)
97.2 (84.2 to 110.2)
109.9 (99.1 to 120.7)
–1.0 (–4.4 to 2.4)
–1.1 (–4.0 to 1.7)
3.2 (2.0 to 4.4)
36.6 (32.5 to 40.8)
34.8 (31.6 to 38.0)
37.1 (33.8 to 40.4)
35.9 (31.9 to 39.9)
33.7 (30.4 to 37.1)
37.9 (34.3 to 41.4)
–1.9 (–5.0 to 1.1)
–3.3 (–5.6 to –1.0)
2.0 (0.4 to 3.6)
0.0021 0.002 0.03
98.7 (98.1 to 99.4)
98.2 (96.6 to 99.9)
99.0 (98.4 to 99.7)
98.4 (97.5 to 99.2)
97.2 (94.0 to 100.3)
99.0 (98.4 to 99.6)
–0.4 (–0.7 to –0.0)
–1.1 (–2.8 to 0.5)
0.0 (–0.1 to 0.2)
2.33 (2.09 to 2.57)
2.28 (1.99 to 2.57)
2.43 (2.21 to 2.65)
2.24 (1.97 to 2.51)
2.16 (1.80 to 2.52)
2.45 (2.22 to 2.68)
–3.9 (–6.8 to –1.0)
–6.5 (–11.8 to –1.2)
0.8 (–0.5 to 2.1)
0.001 0.7 0.0010.006
104.6 (94.9 to 114.3)
102.8 (95.3 to 110.4)
109.8 (102.7 to 116.9)
102.3 (92.8 to 111.8)
102.0 (91.2 to 112.8)
110.6 (102.3 to 119.0)
–2.1 (–4.6 to 0.4)
–1.2 (–5.2 to 2.9)
0.6 (–1.4 to 2.6)
Summary of intervention attendance data
11 (21.4) 0.5
0.2Preintervention sample size, n
Postintervention sample size,
Week of drop out, mean (range)
Number of sessions attended by
15.9 (15–16) 15.1 (11–16)
*All participants in the wait list control (WLC) group attended one counselling
appointment with an exercise specialist and registered dietitian; three partici-
pants did not complete postintervention testing. HIP Healthy Initiatives
Program; YLP Youth Lifestyle Program
Managing adolescent obesity
Paediatr Child Health Vol 16 No 6 June/July 2011349
intervention attrition levels can influence the effectiveness of
weight management care for obese adolescents.
Both YLP and HIP demonstrated that one-on-one lifestyle
coaching interventions can improve some short-term measures of
obesity in adolescents. The magnitude of change in BMI z-score in
the YLP and HIP groups was modest but consistent with recom-
mendations (5). YLP and HIP were designed to improve lifestyle
behaviours, but no significant differences were noted in diet
and physical activity. As well, despite showing improvements in
anthropometric measures, we did not observe concurrent changes
in metabolic risk. We noted favourable patterns of change in sys-
tolic blood pressure, fasting insulin and triglycerides – measures
that are often elevated in obese boys and girls (30); however, none
of these changes achieved significance. The small sample size of
the present study and the within-group variability likely explain
our inability to detect group differences in these variables. In addi-
tion, beyond any short-term effects, it is possible that either YLP
or HIP will prove to be the superior intervention over the long
term – a finding that is not immediately evident.
Expert recommendations endorse the use of patient-centred,
motivation-based approaches to weight management care (4,5).
The HIP intervention included motivational interviewing and cog-
nitive behavioural therapy to help participants address ambivalence
and barriers to behaviour change as well as incorporate specific
problem-solving techniques; however, treatment effects were not
different from the YLP intervention, which simply emphasized tech-
niques such as goal setting and self-monitoring. It is possible that the
use of motivational interviewing and cognitive behavioural therapy
for promoting behaviour change are not universally beneficial for all
obese individuals (31). These approaches may be best applied when
self-efficacy for making lifestyle changes is low or at later stages of an
intervention after setbacks have occurred. Furthermore, testing dif-
ferent weight management approaches in expertise-based trials,
whereby clinicians select their preferred intervention approach,
would capitalize on individual skills and training (32) that tend to
vary within and between disciplines.
Other variables may also explain the similar short-term benefits
(in some outcomes) accrued by participants in the YLP and HIP
interventions compared with the WLC group. For example, contact
frequency has a positive influence on weight management success
(33). The YLP and HIP groups had more than 20 clinical encoun-
ters, which included their intervention sessions as well as pre- and
postintervention testing. Comparatively, adolescents in the WLC
group had five to seven clinical encounters. In our clinic, we have
cultivated a supportive, nonjudgemental setting to help families
make healthy lifestyle changes. If participants received this support
through our clinical environment, and benefitted from the struc-
tured curriculum and self-monitoring built into both interventions,
it is possible that these benefits prevented us from differentiating
between the YLP and HIP intervention effects.
Intention-to-treat analyses have become increasingly popu-
lar in weight management research to minimize study bias and
retain methodological rigour (34,35), and were included in
the present report; however, a qualification is required. In the
present study, participants were in mid-to-late puberty; therefore,
developmental height and weight increases were expected. Using
intention-to-treat and data imputation to include participants
who dropped out before study completion, we carried forward the
last available measurements (preintervention) to the postinter-
vention time point. We believe that this may have provided a
somewhat misleading estimate of the intervention effects. With
intention-to-treat analyses, imputing noncompleters’ baseline data
confers some degree of treatment success because they appear to be
weight stable during the intervention period, which is a laudable
treatment goal (5). However, in the absence of an intervention or
with poor intervention adherence, weight gain would be expected
over the study period, and its trajectory would vary according to
developmental stage. Based on these issues, we analyzed our data
using both completers-only and intention-to-treat techniques.
Several research challenges and clinically relevant observations
emerged from the present study. The long-term maintenance of
weight loss is the true benchmark of weight management success.
While our data do not meet this standard, we provide evidence that
YLP and HIP are feasible in the short term. A lack of long-term
follow-up data limits our ability to comment on the sustainability of
weight management or lifestyle behaviour changes. Effective reten-
tion strategies for children with chronic illnesses may provide
insight into how best to remain engaged with obese adolescents and
their families because attrition is common in paediatric weight
management (36). The level of attrition of our study was similar to
other weight management interventions delivered in an outpatient
setting (37) and highlights what happens under real-world condi-
tions. While issues regarding attrition have been examined to a
limited degree in the treatment of paediatric obesity (38-40), none
have explored families’ reasons for lack of engagement after being
referred for multidisciplinary care. Given the high number of ado-
lescents who failed to initiate care, gaining a better understanding
of factors that explain why some families initiate care while others
do not represents a knowledge gap. Intra- and/or interpersonal fac-
tors (ie, depression or anxiety) may underlie the lack of engage-
ment and initiation of some individuals in weight management
care. While our mental health professionals’ screening assessment
provided a clinical perspective of participants at baseline, the
absence of validated surveys to measure any psychosocial constructs
precluded us from exploring these factors in detail.
When we performed the present study, our clinic offered the YLP
and HIP interventions exclusively; therefore, the 13 adolescents who
attended our group-based orientation session, but did not continue on
to complete preintervention testing, may have benefitted from
alternative treatments. As our clinic evolved, we developed addi-
tional therapeutic options (ie, psychological counselling and personal
fitness training) to complement our structured interventions, which
were enabled by funding and infrastructure – two issues that can limit
program growth and development (11,36). We were also interested in
the experiences of our clinicians who delivered YLP and HIP, as well
as the adolescents who completed the interventions. Anecdotally,
both groups found YLP and HIP to be acceptable, but recommended
adding interactive group-based activities. In our experience, many
boys and girls referred for weight management have small social net-
works; therefore, creating an opportunity for adolescents to interact
with peers may satisfy adolescents’ desire for fun, social interactions
while achieving our clinical aims to minimize intervention attrition,
maintain family engagement and improve health outcomes.
With the high prevalence of paediatric obesity in Canada, there is
an urgent need to deliver and evaluate health services for weight
management. Our study showed that structured interventions can
have a positive, albeit modest, impact on weight management for
some obese boys and girls. However, to best support obese adoles-
cents, initiatives to optimize the initiation of care, develop flex-
ible, multidisciplinary treatment models and reduce intervention
attrition are required. Conducting this research in real-world set-
tings will help to build on existing weight management evidence
and generate information that will be most meaningful to paedia-
tricians and other clinicians.
Ball et al
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ACKNOWLEDGEMENTS: The authors thank all of the adoles-
cents and families who participated in this study, as well as the clini-
cians at the Pediatric Centre for Weight and Health (Stollery
Children’s Hospital, Edmonton) for their clinical and administrative
support. Dr Lonnie Zwaigenbaum provided a critique of an earlier ver-
sion of this manuscript; his time and feedback are sincerely appreci-
ated. Statistical analyses were supported by the Women and Children’s
Health Research Institute (Edmonton). Funding for this research was
provided through an Establishment Grant (awarded to GDCB) by the
Alberta Heritage Foundation for Medical Research (AHFMR) and the
Alberta Health Services’ Weight Wise program. GDCB was supported
by a Population Health Investigator Award from AHFMR and a New
Investigator Award from the CIHR. MSN was supported by a Career
Development Award from the Canadian Child Health Clinician
Scientist Program (a CIHR-funded program). RCP was supported by a
Health Scholar Award from AHFMR and an Applied Public Health
Chair from CIHR. MIG was supported by the Dr Robert C and
Veronica Atkins Endowed Chair in Childhood Obesity and Diabetes.
CONFLICTS OF INTEREST: The authors have no conflicts of
interest to declare.