Managing paediatric obesity: a multidisciplinary intervention including peers in the therapeutic process

Paediatric overweight and obesity have reached epidemic proportions in most industrialised countries [1]. In Portugal, a Southern European country with a traditional Mediterranean diet, the prevalence of overweight adolescents is among the highest in Europe. In a recent study [2], using a representative sample of Portuguese young people (22048 adolescents) aged between 10 and 18 years, there was an estimated prevalence of overweight and obesity of 23.1% and 9.6%, among girls and of 20.4% and 10.3% among boys, respectively. It was also seen that the prevalence of overweight and obesity decreases with age for boys and for girls from 13 to 18.

It is of the utmost importance to work on prevention to deal with this epidemic [3, 4]. However, efforts must also be made to treat those young people who are already overweight [1, 5]. There are several facts to support this need, in particular because adolescent obesity: a) has a significant impact on physical and psychosocial health [6]; b) is an independent risk factor for adult obesity [7]; c) is an independent risk factor for mortality in adults, perhaps more powerful than adult obesity itself [8]; and d) is a major threat to the sustained increase of life expectancy [9].

The psychosocial consequences represent the most prevalent co-morbidities associated with obesity [10]. Obese young people have low self-esteem (SE) and a reduced quality of life (QoL), mainly associated with their perceptions of physical appearance, athletic skills and social functioning [6]. There seems to be a dose–response association between the Body Mass Index (BMI) and a worse health related QoL in such a way that severely obese people have significantly higher values than those seen in people with a less severe degree of obesity [11]. Moreover, obese individuals show higher levels of body dissatisfaction [12] and higher levels of depression [13]. Body Image (BI) has been consistently identified as a protection factor against the development of risky behaviour associated with obesity [14].

Obese adolescents with low levels of self-esteem have shown significantly higher levels of sadness, loneliness and anxiety and are more susceptible to engage in experimental/risky behaviours [9], such as smoking or drinking [15]. Fonseca and Matos [16] showed that overweight adolescents find it harder to make new friends when compared with their peers who are not overweight.

The questions of physical fitness associated with health are increasingly determinant in the way young people negotiate their daily lives and prepare for the future. In adolescents, a low cardiorespiratory fitness value is closely associated with an increased risk for developing cardiovascular diseases, regardless of country, age or gender [17]. To avoid the accumulation of risk factors for the development of cardiovascular diseases, the European Youth Heart Study[18] recommends that young people should perform more than one hour of moderate to vigorous physical activity (MVPA) per day. It has further been identified that higher amounts of MVPA hours are associated with a decrease in cardiometabolic risk factors [19]. However, an increase in physical activity (PA) alone does not solve the problem, as a decrease in sedentary behaviours (e.g. screen time) is crucial metabolic risk and adiposity control [20].

The health of individuals does not come only from their biology and/or individual actions but also from the biology and actions of those around them [21]. This issue is particularly relevant in adolescence as friends play an essential role in the developmental process, through the emotional support that is associated with social affection. Very often, peers are referred to as a barrier to regular PA and healthy diet [22]. More studies are needed to better understand these reciprocal influences, in order to be able to deal in a more effective way with the psychosocial factors negatively impacting the life of the obese adolescent [23]. Interventions that are intended to improve self-efficacy and social functioning in young people can bring specific benefits to obese adolescents [24]. However, and despite different authors e.g. [25], having suggested that an increase support from peers in contexts of PA implementation may constitute a viable way of promoting active lifestyles among young people, this area has still not been much studied.

Although the literature consistently points out the direction for solving the problem, it has generally not been possible to directly and effectively influence PA [26]. Interventions using mediators have shown effective results in changing behaviour in the short term and there is increasing evidence that this approach may have long-term effects [27]. The role of self-efficacy has been clearly pointed to as a mediator in the relationship between the intervention and PA [28]. Recently, Rhodes and Pfaeffli [29], in a wide-reaching review, suggested that changes in the structure of self-regulation might have a greater mediator effect on changing behaviour relative to PA.

Our program, named Tratamento da Obesidade Pediátrica (TOP), standing for Paediatric Obesity Treatment, has been implemented in 2004, and is the result of the cooperation between the Paediatric Obesity Clinic, Department of Paediatrics, at Hospital de Santa Maria (HSM) and the Faculty of Physical Education and Sport at Universidade Lusófona (UL) in Lisbon. This initiative gave rise to an innovative, yet sustained programme where several disciplines including PA specialists are simultaneously present in the Clinic, making it possible that adolescents receive integrated medical, nutritional and PA care on the same day. Respecting the most recent recommendations [30], we use behaviour modifying techniques aimed not only at the adolescents but also at their families and peers, using techniques based on the Self Determination Theory (SDT) and Motivational Interviewing (MI) [31] within a treatment protocol that has been presented at the Society for Adolescent Health and Medicine [32]. Based on our previous experience and on recent literature, it was theorised that to provide better care it would be necessary: a) more extensive and frequent contact with the treatment team and b) the inclusion of peers to assist in the weight control tasks. The literature shows that an adolescent’s health behaviour is associated with that of their peers [23], through social contagion [33, 34] mechanisms. The reasoning behind the design of this project is the belief that providing regular PA, interactive sessions (IS) [35] and specific moments of concentrated intervention – holiday camps [36], would offer the right context for both reaching a more extensive contact with the treatment team and allow for the inclusion of peers in the treatment. This intervention is grounded on the rationale presented and the health behaviour modification model, based on the Self-Determination Theory - SDT [37]. The team believes that this interaction between PA, positive psychological effects and reduction in BMI will lead to an increase in the perceived well-being of adolescents, which in turn will reinforce health behaviour, as has been seen with adults [38].

The aetiology of paediatric obesity is influenced by biological, physiological, environmental and contextual factors [59], with human behaviour being the aggregator factor not only in obesity but in health in general [60]. This intervention is mainly intended for a better understanding of how behaviour can be modified.

Adolescence is that time in life where the ability to learn increases and new habits are adopted [61]. This issue is one of the strongest aspects of the intervention, which intends to enhance the perspective of positive health both based on the increasing individual autonomy and on the peer group interaction as a key element for understanding and potentiating various positive kinds of behaviours [62].

It is well known that only a small part of the populations undergoing interventions to lose weight actually succeed (and maintain) in the long term. Usually, as soon as the intervention ends, PA tends to decrease. As such, and as it is not possible to intervene directly in PA, where should we intervene? Research has shown how motivational processes may play a crucial role as mediators of behavioural change and maintenance [63]. Thøgersen-Ntoumani and Ntoumanis [64] showed the importance of encouraging self-determined motivation in order to improve the quality of the experience and the perpetuation of the behavioural change through exercise.

The sensation of choice or desire when facing a specific behaviour, places the individual in a privileged position in the motivation continuum [63], and can be manipulated through self-regulation. We believe this is a central question, given that SDT proposes that PA can be intrinsically motivated through increasing autonomy and skills development [63].

It is hoped that the results of this trial will contribute to increasing the knowledge on the different processes involved in the management of paediatric obesity (how, when, in which ways and why) and will enable to provide some answers that will for sure merit to be further explored.