Although obesity is a prevalent condition in the United States, overweight individuals are often discriminated against and face numerous practical challenges. In addition, many overweight individuals may be hesitant to seek treatment or feel discomfort with the treatment process. Therefore, it is important that clinicians take steps to ensure that obese individuals receive treatment in an environment that is sensitive to the stigma and challenges faced by the overweight, and concrete steps are taken to reduce potential bias against overweight individuals. Specifically, staff members should receive sensitivity training regarding screening and assessment of eating- and weight-related behaviors, in addition to training in how to interact with overweight children in a non-stigmatizing or discriminating manner. Clinics can also address practical concerns by ensuring that treatment facilities are designed to accommodate the physical and space needs of overweight clients. Overall, minimizing client discomfort within the treatment setting can help improve adherence and treatment uptake.
Implementing socio-environmentally-based interventions within the clinic setting requires clinicians to encourage and facilitate contexts which making healthy eating and behaviors the default. Optimally, this involves delivering interventions tailored to address eating- and weight-related behaviors on multiple levels: the individual, family, and community. To enhance the success of socio-environmentally- based interventions, clinicians must allow ample time to modify the default unhealthful dietary practices and sedentary behaviors. Clinicians may assist parents in the use of positive reinforcement strategies to increase the occurrence of desired healthful behaviors, while simultaneously targeting the decrease of punishment for unwanted, unhealthy behaviors (Epstein et al., 2001
). For example, clinicians can teach parents to provide positive rewards for children’s healthful lifestyles changes (e.g., eating 5 servings of fruits and vegetables, decreasing sedentary behavior) and to minimize attention to and punishment for unhealthy behaviors (e.g., taking away privileges for watching too much television). For instance, clinicians can help patients create a hierarchical list of reinforcing healthful activities and work with the parents and their children to progressively incorporate difficult activities into their lives. Clinicians can also assist individuals struggling with eating- and weight-related concerns by providing opportunities to practice new behaviors across multiple contexts (i.e., at home with family, eating out with friends, at work) that extend beyond the consultation setting. Incorporating family members or friends in the intervention is one method that clinicians can use to help facilitate a social support network for weight loss maintenance.
It is important to consider that factors beyond the individuals’ control may constrain their ability to adopt healthful eating- and weight-related behaviors. Some key factors include socio-economic status, racial/ethnic identity and associated dietary and activity preferences, and residing within a food desert or unsafe neighborhood. Clinicians must be aware of and sensitive to these individual differences, and can work with clients to problem-solve methods to overcome barriers. For example, clinicians can help families who live in food deserts or in areas with aesthetically unappealing places for physical activity to generate practical alternatives (e.g., locating boys and girls clubs in the area). Finding ways to use community resources will promote greater behavioral adherence to family-based interventions. Moreover, it is important to acknowledge the factors that may enhance an individual’s ability to enact eating- and weight-related changes (i.e., strong social support for weight loss maintenance) and capitalized upon these factors during treatment delivery.
Due to the high comorbidity of overweight and psychiatric or medical conditions (Faith et al., 2001
; Tanofsky- Kraff et al., 2003
), clinicians must be prepared to assess for and potentially treat comorbidities within the context of lifestyle interventions. The most common comorbid conditions in youth include depression, eating disorders, and attention deficit/hyperactivity disorder. Approximately 11% of overweight youth seeking behavioral treatment are depressed (Zeller & Modi, 2006
), up to 30% of treatment-seeking overweight individuals meet criteria for BED (Stunkard, 2002
), and nearly 60% of morbidly obese youth have ADHD (Agranat-Meged et al., 2005
). Comorbid conditions commonly related to obesity can effectively be addressed through a multi-level lifestyle approach to weight management. Often, common behavioral components, such as self-monitoring, can be harnessed to treat obesity and related conditions simultaneously.
Finally, for older youth who are severely obese, clinicians can consider the potential benefit of implementing more aggressive treatment approaches, such as bariatric surgery and pharmacotherapy, to lifestyle interventions. Currently, bariatric surgery is indicated for adolescents who are: severely overweight; have reached their adult height; have attempted to lose weight (unsuccessfully) for at least 6 months; and have obesity-related comorbidities (Inge, Xanthakos, & Zeller, 2007
). Clinician involvement, including the assessment of the adolescent’s social and emotional development, is imperative for youth who are considering undergoing bariatric surgery, as the long-term impact of bariatric surgery early in life on development is not yet fully understood (Bean, Stewart, & Olbrisch, 2008
). Although recommendations for the use of pharmacological weight loss therapy in children have not been established, preliminary research suggests that pharmacotherapy may increase the efficacy of lifestyle interventions (Dunican, Desilets, & Montalbano, 2007
) for severely overweight youth. Clinicians can help emphasize that both bariatric surgery and pharmacotherapy is best utilized as an adjunctive treatment to lifestyle behavioral interventions.