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Body Composition Changes in an
Outdoor Behavioral Healthcare Program
Steven M. DeMille,
1
Casey Comart,
2
and Anita Tucker
2
1
RedCliff Ascent Wilderness Treatment Program, Enterprise, Utah.
2
University of New Hampshire, Durham, New Hampshire.
Abstract
This study examined the body composition changes of adolescents
participating in an outdoor behavioral healthcare program. The
sample was grouped by body mass index (BMI) categories of un-
derweight, normal weight, overweight, and obese to discern the
physiological changes across these categories as a result of partici-
pation. In addition, this study tested for gender differences and
differences based on season of enrollment (summer vs. winter).
Paired samples ttests revealed that, on average, adolescent partic-
ipants moved toward healthier body compositions from intake to
discharge. Specifically, underweight participants gained a signifi-
cant amount of weight, predominantly composed of lean mass.
Normal-weight participants stayed at approximately the same
weight but gained lean mass and lost fat mass. Overweight and obese
participants lost significant amounts of weight. Two-way ANOVA
analyses revealed gender differences in terms of weight loss within
BMI categories, yet no differences by season or between the genders
across seasons were found. Key Words: Outdoor behavioral
healthcare—Wilderness therapy—Adolescents—Body composition—
Body mass index (BMI).
Outdoor behavioral healthcare (OBH), also known as wil-
derness therapy, is an innovative approach to behavioral
health treatment (Russell & Phillips-Miller, 2002). While
OBH programs have existed for decades, recent years
have seen an increased development of professionalization, includ-
ing the formation of the Outdoor Behavioral Healthcare Council (Gass
et al., 2012). The OBH Council’s mission is to advance the field ‘‘by
promoting program standards, ethics and risk management plus fa-
cilitating outcome research on the efficacy of wilderness programs’’
(OBH Council, 2013). In addition, an initiative for program accredi-
tation through the Association for Experiential Education (AEE) is the
latest advancement in the standards of practice in the OBH field
(Gass, 2013). This increased focus on professionalization has created
a need for empirical examination of industry practices.
Outdoor behavioral healthcare is an intensive intervention used
with adolescent clients and young adults. Russell and Phillips-Miller
(2002) describe OBH as ‘‘immersion in wilderness or comparable
lands, group living with peers, individual and group therapy sessions,
and educational and therapeutic curricula, including backcountry
travel and wilderness living skills’’ (p. 415). OBH is designed to ad-
dress behavioral and emotional issues, improve social relations, en-
hance levels of personal responsibility, and promote personal growth
in clients (Russell & Phillips-Miller, 2002). Extant OBH outcome re-
search has found it an effective intervention for decreasing mental
health symptoms for both adolescents (Bettmann et al., 2013; Lewis,
2013; Russell, 2003, 2006, 2008; Tucker et al., 2011; Zelov et al.,
2013) and young adults (Hoag et al., 2013); however, little research
has looked specifically at the biological or physiological impact of
OBH on clients.
A study by Jelalian et al. (2006) of a group-based cognitive be-
havioral therapy weight loss program for obese adolescents found
that an added adventure therapy component was related to four times
the average weight loss in older adolescents compared to a similar
group with an added exercise component. These findings suggest that
therapeutic interventions can increase the effectiveness of weight
loss programs; however, this study did not look at OBH but at a
community-based program. A qualitative study by Caulkins et al.
(2006) looked at the therapeutic element of backpacking in an OBH
program for troubled adolescent females. In their study they found
themes of reflection, perceived competence, accomplishment, time-
lessness, awareness of surroundings, awareness of self, awareness of
others, and self-efficacy. However, their study did not look at the
physical changes that occurred as a result of participating in an OBH
174 ECOPSYCHOLOGY SEPTEMBER 2014 DOI: 10.1089/ eco.2014.0012
program. The current study has addressed the gaps in the research
and is the first of its kind to examine the changes in body compo-
sition of adolescents participating in an OBH program. Specific re-
search questions included
(1) What were the changes in body mass index (BMI), weight,
lean mass, muscle mass, and body fat percentage in youth as a
result of participating in an OBH program?
(2) Are there gender differences in physical changes across BMI
levels?
(3) Are there differences in weight changes based on the season
of enrollment?
Method
Participants
The study sample included 2,182 adolescent clients between the
ages of 13 and 18 who enrolled in an OBH treatment program be-
tween January 1, 2002, and December 31, 2012. A majority of the
clients were male (73%) with most clients falling in the normal BMI
weight range at intake (69%). The average length of stay for partic-
ipants was 73 days (SD =23.6). Of the 2,182 initial participants, full
data sets were gathered at intake and discharge on 1,917 clients, 88%
of the original sample. Participants referred to this OBH program
have been previously diagnosed or demonstrated symptoms from a
number of categories. These diagnostic labels are major depression,
bipolar disorder, attention deficit hyperactivity disorder (ADHD),
oppositional defiant disorder (ODD), learning disorder, adjustment
disorder, impulse control disorder, and substance-related disorders.
Provider
This study was a secondary analysis of archival data gathered for
research and program development purposes. Data for this study was
gathered at an OBH treatment program licensed by the Utah De-
partment of Licensing and belonging to the OBH Council. The pro-
gram follows the standards for diet and nutrition outlined by the
State of Utah for youth outdoor programs. Participant’s diet includes
access to 3,000 calories each day; food supplies are assessed and
replenished twice a week. The breakdown for food includes oatmeal,
farina, and powdered milk for breakfast; trail mix, which includes
granola and a variety of dried fruits and nuts, to snack on throughout
the day; rice, beans, lentils, dehydrated potatoes, dehydrated vege-
tables, and whole wheat flour for dinner. Participants received a
variety of fresh fruits, vegetables, 5 oz of fish and meat twice per
week, and an alternating supply of 1 lb of peanut butter or cheddar
cheese each week. During winter months, participant’s diet is sup-
plemented with 4 oz of butter and a pound of salt pork each week.
Hiking/backpacking distances are also adjusted during the winter
months, with the distance average reduced during winter months.
The program used a continuous-flow wilderness trek model. The
primary physical activity was hiking/backpacking. On average, par-
ticipants went on hiking/backpacking expeditions 4–5 times a week for
3–10 miles each trek. Participants received a physical exam within 72
hours of arriving at the program. Based on these assessments, hiking
restrictions were applied for clients in the obese weight category and the
underweight category. In addition, extra protein is added to a client’s
diet if he or she is considered underweight. In addition, client health was
monitored weekly by a registered nurse, and medical concerns were
addressed by a licensed medical doctor. Permission was received from
participants’ guardians/parents at intake to receive medical care and
monitoring throughout the participants’ stay at the program.
Assessment
To monitor physical changes, a BMI and body composition were
calculated for each participant. BMI is a useful assessment and
screening tool used by the World Health Organization (WHO) and
Centers for Disease Control and Prevention (CDC) to assess weight
categories that may lead to health problems. The BMI cutoff values
are less than 18.5 as underweight, 18.5–24.9 representing normal
weight, 25–29.9 as overweight, and 30 or greater representing obese
weight. Body composition is used to assess the percentage of lean
mass and fat mass. To calculate body composition, a bioelectrical
impedance analysis (BIA) device was used. The BIA uses electricity to
determine body fat percent, which is then used to calculate the lean
and fat mass of participants.
Procedures
A time series research design was used to answer the research
questions. Height, weight, and body fat percentages were gathered
from participants at intake to establish a baseline. Immediately after
participants completed the program, height, weight, and body fat
percentages were again gathered from each client. BMI and lean and
fat mass were calculated from this data at both intake and discharge.
Then changes in weight, body fat percentages, lean mass, fat mass,
and BMI between intake and discharge were determined for all par-
ticipants (Table 1). Paired sample ttests were used to determine if
there were significant differences in weight between intake and
discharge across the four BMI categories for the total sample as well
as for males and females. BMI was used as a grouping characteristic,
and weight was used as the variable in analysis, as the numerical
changes in weight are more demonstrative of the physical changes of
BODY COMPOSITION CHANGES IN OUTDOOR BEHAVIORAL HEALTHCARE
ªMARY ANN LIEBERT, INC. VOL. 6 NO. 3 SEPTEMBER 2014 ECOPSYCHOLOGY 175
participants. Bonferroni corrections were computed to account for
risk of Type I errors.
In addition, to explore the differences between gender and BMI
levels in terms of weight changes, a two-way ANOVA of gender
(male, female) and BMI (underweight, normal, overweight, obese) on
mean weight change was conducted. In addition, to explore the re-
lationship between gender and seasonal differences on weight
change, a two-way ANOVA of gender and season (summer, winter)
on weight change was conducted.
Findings
Changes in weight and body composition
Since there are different desired outcomes for youth based on their
intake BMI, weights were compared at intake and discharge for un-
derweight, normal weight, overweight, and obese youth. The mean
change in weight for underweight participants was a gain of 7.5 lb
(SD =7.2), which was statistically significant t(116) =-11.238,
p<.001. Underweight participants gained a mean of 5.7 lb (SD =7.1)
of lean mass and a mean of 1.9 lb (SD =5.7) of fat mass. Underweight
participants also gained a mean of 1.2 (SD =1.2) points of BMI be-
tween intake and discharge. The mean change in weight for normal-
weight participants was a gain of 0.2 lb ( SD =8.9), which was not
statistically significant. Normal-weight participants gained a mean
of 2.9 lb (SD =7.9) of lean mass and lost a mean of 2.7 lb (SD =8.2) of
fat mass. Normal-weight participants also gained a mean of .02
(SD =1.4) points of BMI between intake and discharge. The mean
change in weight for overweight participants was a loss of 12.8 lb
(SD =12.3), which was statistically significant t(323) =18.877,
p<.001. Overweight participants lost a mean of .8 lb (SD =8.7) of
lean mass and a mean of 12 lb (SD =10.9) of fat mass. Overweight
participants also lost a mean of 2 (SD =1.9) points of BMI between
intake and discharge. The mean change in weight for obese partici-
pants was a loss of 35.7 lb (SD =16.8), which was statistically sig-
nificant t(152) =26.311, p<.001. Obese participants lost a mean of
8.7 lb (SD =13.9) of lean mass and a mean of 27lb (SD =16.3) of fat
mass. Obese participants also lost a mean of 5.5 (SD =2.6) points of
BMI between intake and discharge.
Changes across BMI categories for males and females
This study was also interested in understanding what physical
changes were found depending on gender and intake BMI categories.
Tables 2 and 4 highlight the overall changes reported by males.
Tables 3 and 5 highlight the overall changes for females.
Underweight males. Males with an intake BMI below 18.5 (n=89)
were admitted to the program with a mean body weight of 118.3 lb
(SD =11.1). These underweight males were discharged from the
program with a mean weight of 125.2 lb (SD =15.1). The mean
change in weight was a gain of 7.0 lb (SD =7.4). According to a paired
samples ttest, this mean change in weight was statistically signifi-
cant, t(88) =8.910, p<.001 (see Table 4). On average, the underweight
Table 1. Descriptives of Participants by BMI Group
ADMISSION DISCHARGE CHANGE
M SD M SD M SD
Low BMI (below 18.5) (n=117)
Weight (lb) 115.4 11.9 122.9 14.9 7.5 7.2
Body fat (%) 14.2 6.0 14.8 5.9 0.6 4.5
Lean mass (lb) 99.1 13.0 104.7 14.5 5.7 7.1
Fat mass (lb) 16.3 6.8 18.2 7.5 1.9 5.7
BMI 17.7 0.7 18.8 1.4 1.2 1.2
Normal BMI (18.5–24.9) (n=1,323)
Weight (lb) 141.6 18.2 141.8 16.9 0.2 8.9
Body fat (%) 19.9 7.0 18.1 6.4 -1.8 5.1
Lean mass (lb) 113.3 16.6 116.1 16.3 2.9 7.9
Fat mass (lb) 28.3 11.1 25.6 9.6 -2.7 8.2
BMI 21.6 1.7 21.6 1.7 0.0 1.4
Overweight BMI (25–29.9) (n=324)
Weight (lb) 174.3 21.1 161.4 18.2 -12.8 12.3
Body fat (%) 28.8 6.8 23.6 7.0 -5.1 5.2
Lean mass (lb) 124.3 19.9 123.5 19.0 -0.8 8.7
Fat mass (lb) 50.0 12.9 37.9 11.4 -12.0 10.9
BMI 26.9 1.4 24.9 1.8 -2.0 1.9
Obese BMI (30 and above) (n=153)
Weight (lb) 222.9 32.9 187.2 27.6 -35.7 16.8
Body fat (%) 35.5 8.3 27.5 7.8 -7.8 6.0
Lean mass (lb) 144.0 27.3 135.3 22.6 -8.7 13.9
Fat mass (lb) 78.9 23.6 51.9 17.6 -27.0 16.3
BMI 33.8 3.6 28.2 3.1 -5.5 2.6
DEMILLE ET AL.
176 ECOPSYCHOLOGY SEPTEMBER 2014
males gained 6.1 lb of lean mass (SD =7.6) and 0.9 lb of fat mass
(SD =5.5). The average change in BMI for underweight males was 1.0
points of BMI (SD =1.3) (see Table 2).
Normal-weight males. Males with an intake BMI between 18.5 and
24.9 (n=981) were admitted to the program with a mean body weight
of 145.9 lb (SD =17.3). These normal-weight males were discharged
from the program with a mean weight of 145.3 lb (SD =16.3). The
mean change in weight was a loss of 0.7 lb (SD =9.1). According to a
paired samples ttest, this mean change in weight was not statistically
significant. On average, the normal-weight males gained 2.9 lb of
lean mass (SD =8.4) and lost 3.6 lb of fat mass (SD =8.1). The average
Table 2. Descriptives of Males by BMI Group
ADMISSION DISCHARGE CHANGE
M SD M SD M SD
Low BMI (below 18.5) (n=89)
Weight (lb) 118.3 11.1 125.2 15.1 7.0 7.4
Body fat (%) 14.4 5.9 14.1 5.5 -0.3 4.3
Lean mass (lb) 101.3 12.5 107.5 13.5 6.1 7.6
Fat mass (lb) 16.9 6.9 17.8 7.6 0.9 5.5
BMI 17.7 0.8 18.7 1.4 1.0 1.3
Normal BMI (18.5–24.9) (n=981)
Weight (lb) 145.9 17.3 145.3 16.3 -0.7 9.1
Body fat (%) 19.3 7.1 17.0 6.2 -2.3 5.0
Lean mass (lb) 117.5 15.6 120.4 15.1 2.9 8.4
Fat mass (lb) 28.4 11.6 24.8 9.7 -3.6 8.1
BMI 21.6 1.7 21.5 1.6 -0.1 1.4
Overweight BMI (25–29.9) (n=222)
Weight (lb) 182.0 19.0 166.5 17.8 -15.5 12.6
Body fat (%) 27.4 6.9 21.8 7.1 -5.7 5.4
Lean mass (lb) 131.9 17.9 130.3 17.9 -1.7 9.8
Fat mass (lb) 50.1 13.9 36.2 12.2 -13.8 11.2
BMI 26.9 1.4 24.5 1.8 -2.4 1.9
Obese BMI (30 and above) (n=112)
Weight (lb) 229.8 33.0 192.1 28.1 -37.7 16.5
Body fat (%) 33.8 8.7 25.8 7.8 -7.9 6.2
Lean mass (lb) 151.6 26.9 141.8 21.8 -9.8 14.7
Fat mass (lb) 78.2 25.7 50.3 18.5 -27.9 16.7
BMI 33.8 3.5 28.1 3.1 -5.6 2.4
Table 3. Descriptives of Females by BMI Group
ADMISSION DISCHARGE CHANGE
M SD M SD M SD
Low BMI (below 18.5) (n=28)
Weight (lb) 106.1 9.0 115.4 11.6 9.4 6.7
Body fat (%) 13.7 6.4 16.9 6.4 3.3 4.2
Lean mass (lb) 91.8 12.0 96.2 14.3 4.4 5.3
Fat mass (lb) 14.3 6.4 19.3 7.2 5.0 5.3
BMI 17.6 0.6 19.2 1.1 1.6 1.1
Normal BMI (18.5–24.9) (n=342)
Weight (lb) 129.2 14.7 131.7 14.3 2.6 8.2
Body fat (%) 21.6 6.4 21.1 6.0 -0.5 5.1
Lean mass (lb) 101.1 12.8 103.8 13.0 2.7 6.2
Fat mass (lb) 28.1 9.3 27.9 8.7 -0.2 7.8
BMI 21.7 1.7 22.1 1.8 0.4 1.4
Overweight BMI (25–29.9) (n=102)
Weight (lb) 157.3 14.4 150.3 13.5 -7.0 9.0
Body fat (%) 31.6 5.7 27.7 4.6 -3.9 4.5
Lean mass (lb) 107.6 12.5 108.6 11.2 1.1 5.5
Fat mass (lb) 49.8 10.5 41.7 8.5 -8.1 9.2
BMI 26.9 1.4 25.6 1.6 -1.2 1.7
Obese BMI (30 and above) (n=41)
Weight (lb) 203.9 24.2 173.9 21.1 -30.0 16.4
Body fat (%) 39.4 5.1 32.1 5.6 -7.3 5.5
Lean mass (lb) 123.2 14.4 117.6 13.7 -5.6 11.0
Fat mass (lb) 80.7 16.7 56.3 14.2 -24.4 15.0
BMI 33.7 3.8 28.5 3.0 -5.2 3.1
BODY COMPOSITION CHANGES IN OUTDOOR BEHAVIORAL HEALTHCARE
ªMARY ANN LIEBERT, INC. VOL. 6 NO. 3 SEPTEMBER 2014 ECOPSYCHOLOGY 177
change in BMI for normal-weight males was -0.1 points of BMI
(SD =1.4) (see Table 2).
Overweight males. Males with an intake BMI between 25 and 29.9
(n=222) were admitted to the program with a mean body weight of
182.0 lb (SD =19.0). These overweight males were discharged from
the program with a mean weight of 166.5 lb (SD =17.8). The mean
change in weight was a loss of 15.5 lb (SD =12.6). According to a
paired samples ttest, this mean change in weight was statistically
significant, t(221) =-18.274, p<.001 (see Table 4). On average, the
overweight males lost 1.7 lb of lean mass (SD =9.8) and lost 13.8 lb of
fat mass (SD =11.2). The average change in BMI for overweight males
was -2.4 points of BMI (SD =1.9) (see Table 2).
Obese males. Males with an intake BMI 30 or over (n=112) were
admitted to the program with a mean body weight of 229.8 lb
(SD =33.0). These obese males were discharged from the program
with a mean weight of 192.1 lb (SD =28.1). The mean change in
weight was a loss of 37.7 lb (SD =16.5). According to a paired samples
ttest, this mean change in weight was statistically significant,
t(111) =-24.218, p<.001 (see Table 4). On average, the obese males
lost 9.8 lb of lean mass (SD =14.7) and lost 27.9 lb of fat mass
(SD =16.7). The average change in BMI for obese males was -5.6
points of BMI (SD =2.4) (see Table 2).
Underweight females. Females with an intake BMI below 18.5
(n=28) were admitted to the program with a mean body weight of
106.1 lb (SD =9.0). These underweight females were discharged from
the program with a mean weight of 115.4 lb (SD =11.6). The mean
change in weight was a gain of 9.4 lb (SD =6.7). According to a paired
samples ttest, this mean change in weight was statistically signifi-
cant, t(27) =7.432, p<.001 (see Table 5). On average, the underweight
females gained 4.4 lb of lean mass (SD =5.3) and 5.0 lb of fat mass
(SD =5.3). The average change in BMI for underweight females was
1.6 points of BMI (SD =1.1) (see Table 3).
Normal-weight females. Females with an intake BMI between 18.5
and 24.9 (n=342) were admitted to the program with a mean body
weight of 129.2 lb (SD =14.7). These normal-weight females were
discharged from the program with a mean weight of 131.7lb
(SD =14.3). The mean change in weight was a gain of 2.6 lb (SD =8.2).
According to a paired samples ttest, this mean change in weight was
statistically significant, t(341)=5.791, p<.001 (see Table 5). On av-
erage, the normal-weight females gained 2.7 lb of lean mass (SD=6.2)
and lost 0.2 lb of fat mass (SD =7.8). The average change in BMI for
normal-weight females was 0.4 points of BMI (SD =1.4) (see Table 3).
Overweight females. Females with an intake BMI between 25 and
29.9 (n=102) were admitted to the program with a mean body weight
of 157.3 lb (S=14.4). These overweight females were discharged from
the program with a mean weight of 150.3 lb (SD =13.5). The mean
change in weight was a loss of 7.0 lb (SD =9.0). According to a paired
Table 4. Male Changes in Weight by Admission BMI tTest
n
MEAN
DIFFERENCE
(LB) tdfp*
BMI at admission
Underweight
(below 18.5)
89 7.0 8.910 88 <.001
Normal
(18.5–24.9)
981 -0.7 -2.288 980 0.09
Overweight
(25–29.9)
222 -15.5 -18.274 221 <.001
Obese
(30 and over)
112 -37.7 -24.218 111 <.001
*Bonferroni corrected pvalues.
Table 5. Female Changes in Weight by Admission
BMI tTest
n
MEAN
DIFFERENCE
(LB) tdfp*
BMI at admission
Underweight
(below 18.5)
28 9.4 7.432 27 <.001
Normal
(18.5–24.9)
342 2.6 5.791 341 <.001
Overweight
(25–29.9)
102 -7.0 -7.940 101 <.001
Obese
(30 and over)
41 -30.0 -11.714 40 <.001
*Bonferroni corrected pvalues.
DEMILLE ET AL.
178 ECOPSYCHOLOGY SEPTEMBER 2014
samples ttest, this mean change in weight was statistically signifi-
cant, t(101) =-7.940, p<.001 (see Table 5). On average, the over-
weight females gained 1.1 lb of lean mass (SD =5.5) and lost 8.1 lb of
fat mass (SD =9.2). The average change in BMI for overweight fe-
males was -1.2 points of BMI (SD =1.7) (see Table 3).
Obese females. Females with an intake BMI 30 or over (n=41) were
admitted to the program with a mean body weight of 203.9 lb
(SD =24.2). These obese females were discharged from the program
with a mean weight of 173.9 lb (SD =21.1). The mean change in
weight was a loss of 30.0 lb (SD =16.4). According to a paired samples
ttest, this mean change in weight was statistically significant,
t(40) =-11.714, p<.001 (see Table 5). On average, the obese females
lost 5.6 lb of lean mass (SD =11.0) and lost 24.4 lb of fat mass
(SD =15.0). The average change in BMI for obese females was -5.2
points of BMI (SD =3.1) (see Table 3).
Gender comparisons across BMI categories. Table 8 shows the
comparisons of mean weight changes between males and females
across BMI categories. Although the results of the 2 ·4 ANOVA
showed that the main effect of gender on mean weight changes was
significant, F(1, 1909) =47.5, p<.001, as was the main effect of BMI
categories, F(3, 1909) =523, p<.001, there was a significant inter-
action between gender and BMI categories, F(3, 1909) =6.3, p<.001.
Underweight females gained more weight (M=9.3, SD =6.6) than
underweight males (M=6.9, SD =7.3), while overweight and obese
males lost more weight than females. Hence, changes in weight dif-
fered depending on BMI level of males and females.
Seasonal comparisons
This study also examined the effects of seasonal differences in
body composition changes of program participants for both males
and females. Tables 6 and 7 describe in depth the body composition
changes for males and females across seasons. As shown in Table 8,
the average change in weight from admission to discharge for males
during the summer months (April–September) was -6.3 lb
(SD =14.8). The change in weight for males during the winter months
(October–March) was -4.4 lb (SD =15.7). The average change in
weight from admission to discharge for females during the summer
months (April–September) was -1.5 lb (SD =12.4). The change in
weight for females during the winter months (October–March) was
-1.7 lb (SD =14.0). Results of the 2 ·2 ANOVA showed a significant
main effect of gender on mean weight changes, F(1, 1913) =24.3,
p<.001. Males on average lost -5.5 lb (SD =15.2) more than females
(-1.6 lb, SD =13.1). Weight changes did not significantly differ
Table 6. Descriptives of Males by Season
ADMISSION DISCHARGE CHANGE
M SD M SD M SD
Summer months (April–September) (n=801)
Weight (lb) 156.3 31.8 150.0 23.3 -6.3 14.8
Body fat (%) 21.3 8.5 17.7 7.0 -3.6 5.4
Lean mass (lb) 121.4 19.1 122.9 17.9 1.5 9.5
Fat mass (lb) 34.9 20.2 27.1 13.3 -7.8 12.0
BMI 23.1 4.2 22.1 2.8 -1.0 2.2
Winter months (October–March) (n=603)
Weight (lb) 156.9 33.7 152.5 23.5 -4.4 15.7
Body fat (%) 21.6 9.0 19.0 7.1 -2.6 5.5
Lean mass (lb) 121.6 21.9 122.8 17.6 1.2 10.6
Fat mass (lb) 35.3 20.7 29.6 13.9 -5.6 11.9
BMI 23.2 4.4 22.6 2.8 -0.7 2.4
Table 7. Descriptives of Females by Season
ADMISSION DISCHARGE CHANGE
M SD M SD M SD
Summer months (April–September) (n=276)
Weight (lb) 138.6 27.8 137.1 20.6 -1.5 12.4
Body fat (%) 24.9 8.9 23.2 6.6 -1.6 5.5
Lean mass (lb) 102.5 14.8 104.6 13.8 2.1 7.1
Fat mass (lb) 36.0 19.1 32.5 12.7 -3.5 11.1
BMI 23.4 4.3 23.1 3.0 -0.3 2.3
Winter months (October–March) (n=237)
Weight (lb) 140.5 27.5 138.8 19.4 -1.7 14.0
Body fat (%) 24.2 8.7 22.8 7.2 -1.4 5.5
Lean mass (lb) 104.9 14.1 106.4 13.1 1.5 6.6
Fat mass (lb) 35.6 19.3 32.4 13.4 -3.2 11.6
BMI 23.5 4.2 23.2 2.9 -0.3 2.3
BODY COMPOSITION CHANGES IN OUTDOOR BEHAVIORAL HEALTHCARE
ªMARY ANN LIEBERT, INC. VOL. 6 NO. 3 SEPTEMBER 2014 ECOPSYCHOLOGY 179
between winter and summer months, F(1, 1913) =1.2, p=.270. The
interaction between gender and season was not significant, F(1,
1913) =1.9, p=.16. Hence, although males lost more weight than
females, there did not appear to be any differences in weight changes
across seasons, regardless of gender.
Discussion
The overall findings of this study suggest that adolescents in this
OBH program moved toward healthy body composition between
intake and discharge. Underweight participants gained a significant
amount of weight, composed predominantly of lean mass. On aver-
age, normal-weight participants showed no net change in weight;
however, they did gain lean mass and lose fat mass. Both overweight
and obese participants lost a significant amount of weight. On av-
erage, participants in all the groups moved toward healthier weights
as well as healthier ratios of lean and fat mass.
There were some gender differences in body composition changes
from intake to discharge. Both underweight male and female par-
ticipants gained significant amounts of weight. The underweight
males gained predominantly lean mass, while the females gained a
blend of lean and fat mass. Normal-weight males lost a small but
significant amount of weight; however, the relatively small change in
weight was actually composed of a larger shift to more lean mass and
less fat mass. In addition, normal-weight females gained some
weight, exclusively in the form of lean mass. Obese and overweight
males and females all lost some lean mass and large amounts of fat
mass, resulting in significant weight loss. Statistics report that on
average males lost more weight than females.
Living conditions are different between summer and winter
months. These differences require adjustments in client’s diet and
physical activity. This study found that adolescent males enrolled in
the summer months lost 2 more pounds of weight than those enrolled
in the winter months, yet this difference was not found to be large
enough to be considered statistically significant. These findings
suggest that this OBH program can provide a healthy balance of
exercise and physical activity in summer and winter months.
Adolescence is a time of marked physical and mental development
(Broderick & Blewitt, 2010). In addition to these changes, many ad-
olescents are at significant risk of weight-related issues (Huh et al.,
2012). Adolescent weight issues have been identified as a concern in
the United States (Lawrence et al., 2010; Peart et al., 2011; Swanson
et al., 2011). Furthermore, research suggests there may be a rela-
tionship between adolescent weight issues and emotional, behav-
ioral, and substance abuse problems (Bjornelv et al., 2011; McClure
et al., 2012; Pasch et al., 2012). The promising body composition
findings of this study may provide fertile ground for further explo-
ration of the clinical benefits of improving physical fitness while
participating in an OBH program.
Despite the promising movement toward healthy BMI found be-
tween intake and discharge, it is unclear whether the weight changes,
Table 8. Comparisons of Changes in Weight Between Males and Females Across BMI Categories and Seasons (N=1917)
MALES FEMALES TOTAL
MSDn MSDn MSDn
Changes in weight (lb)
Underweight (BMI under 18.5) 6.9 7.3 89 9.3 6.6 28 7.5 7.2 117
Normal weight (BMI 18.5–24.9) -.66 9.1 981 2.5 8.1 342 .17 8.9 1323
Overweight (BMI 25–29.9) -15.5 12.6 222 -7.0 9.0 102 -12.8 12.2 324
Obese (BMI 30 and over) -37.7 16.5 112 -30.0 16.4 41 -35.7 16.7 153
Total -5.5 15.2 1404 -1.6 13.1 513 -4.4 14.8 1917
Changes in weight (lb)
Summer months (April–September) -6.3 14.8 801 -1.5 12.4 276 -5.1 14.4 1077
Winter months (October–March) -4.4 15.7 603 -1.7 14.0 237 -3.6 15.3 840
Total -5.5 15.2 1404 -1.6 13.1 513 -4.4 14.8 1917
DEMILLE ET AL.
180 ECOPSYCHOLOGY SEPTEMBER 2014
especially large losses of weight, are within healthy parameters. Most
diet and exercise approaches specify that a reasonable and healthy
weekly weight loss is 1–2 lb a day (CDC, 2013). Some of the weight
loss found in this study exceeded that parameter. Although specific
reasons cannot be identified, this weight loss is likely explained by an
often drastic change in diet, physical activity, and lifestyle (especially
substance usage). Furthermore, the increased water intake or the
frequent backpacking and hiking in a trek-model wilderness therapy
program may account for some of the weight changes. In addition,
some participants’ weight changes may be effected by stopping or
starting a psychotropic medication, yet in the study, this was not
specifically tracked. In general, it is not uncommon for youth to stop
taking their medication. In addition, it is unclear whether the rela-
tively rapid loss of large amounts of weight is ultimately healthy for
participants. There is limited research describing healthy parameters
for rapid adolescent weight loss. The most relevant research addresses
health concerns related to rapid weight loss in professional athletes;
however, the rapid weight loss achieved by professional athletes
tends to be more rapid than the weight loss observed in this study and
is achieved through more extreme methods (Sundgot-Borgen &
Garthe, 2011). Clearly, more research is needed in this area.
A variety of professionals and organizations in the United States
have criticized OBH health and safety practices (Behar et al., 2007;
Friedman et al., 2006; GAO, 2007). Among their concerns are issues
of malnutrition or otherwise inadequate sustenance (GAO, 2007). For
example, a 2001 death investigated by a 2007 Government Ac-
countability Office (GAO) report found an adolescent had died due to
dehydration and malnutrition; the child’s diet at the program had
been restricted to an apple for breakfast, a carrot for lunch, and a
bowl of beans for dinner while the child was required to participate in
rigorous physical activity in harsh environmental conditions (GAO,
2007). This death and others were also related to exercise in high heat,
poorly trained staff, inadequate equipment, and reckless operating
practices (GAO, 2007).
In Utah, a state with a large concentration of OBH programs, state
law R501-8 regulates various aspects of operating practices for OBH
programs. Included in these regulations are specifications for water
and nutritional requirements. Six or more quarts of water must be
available each day as well as electrolyte supplements. A minimum of
3,000 calories must be provided each day, which can be adjusted for a
30–100% increase in accordance with increased energy expenditure
or climate conditions. Fresh vegetables and fruit must be provided
twice a week, as well as a daily vitamin supplement. This law also
dictates temperatures during which hiking is forbidden, as well as
standards for ongoing medical evaluation of adolescents. The find-
ings of this study suggest that if OBH programs are operated in
compliance with Utah state law, program participants are likely to
experience healthy weight changes. Furthermore, participants in
compliant programs may potentially be at less risk for operating
practices that jeopardize safety through improper nutrition and ex-
ercise.
This explorative study was the first to look in depth at the changes
in body composition of OBH participants and found promising re-
sults; however, more research is needed to explore the long-term
impacts of the program on body composition and if those changes are
sustainable. In addition, future research looking at how changes in
body composition during the program correspond with mental health
improvements is needed in order to gain a more holistic picture of the
impact of OBH on the physical and emotional health of youth. Ad-
ditionally, further research is needed to identify which components
of the program (increased water intake, healthy diet, increased
physical activity, change in medications) influence the changes in
weight. Regardless, this study is the first step needed to gain a better
understanding of how expeditions can improve physical health.
There may be hesitancy to enroll an adolescent in an OBH program
due to physical limitation from being overweight; however, this did
not seem to impact participation. There was no significant correlation
between intake BMI and length of stay, suggesting that clients’ length
of stay was determined by clinical progress rather than physical
fitness at the time of intake. In addition, these findings support
previous research that, although OBH is seen as putting participants
at risk due to the nature of the intervention, it can be in fact less risky
than keeping youth in their home environments ( Javorski & Gass,
2013).
Author Disclosure Statement
Steven DeMille is employed by RedCliff Ascent, the outdoor be-
havioral healthcare program where the data was gathered. Steven
was not involved in the data collection or analysis.
CaseyComartwasnotpaidforhisinvolvement in the study and is not
on staff or formally affiliated with the program involved in this project.
Anita Tucker was not paid for her involvement in the study and is
not on staff or formally affiliated with the program involved in this
project.
Data for this secondary analysis was stored in a HIPPA-compliant
database. Parental permission was received to gather data, and
identifying information was removed prior to the data analysis. IRB
approval is not required by the University of New Hampshire for
secondary analysis of data.
BODY COMPOSITION CHANGES IN OUTDOOR BEHAVIORAL HEALTHCARE
ªMARY ANN LIEBERT, INC. VOL. 6 NO. 3 SEPTEMBER 2014 ECOPSYCHOLOGY 181
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Address correspondence to:
Steve DeMille
RedCliff Ascent
709 E Main St.
Enterprise, UT 84725
E-mail: steved@redcliffascent.com
Received: January 28, 2014
Accepted: April 5, 2014
DEMILLE ET AL.
182 ECOPSYCHOLOGY SEPTEMBER 2014
