Motivation and emotion/Book/2014/Weight loss motivation in overweight children

Overview
This chapter explores the way that motivation affects weight loss in overweight children. The chapter is divided into two different age groups: early and middle childhood, and adolescence. Through these age groups this chapter looks at:
 * the factors affecting weight gain in children,
 * how to motivate parents to help their child lose weight,
 * the theories behind motivating an overweight child, and
 * how to put these theories into practice to help the overweight child.

Reading through and then attempting the case studies at the end of each age group will help to apply the concepts discussed throughout the chapter to real world scenarios.

A quarter of Australian children
According to the Australian Bureau of Statistics, in 2011-12, 25.1% of Australian children aged 2–17 years were overweight or obese (2013). Furthermore, the proportion of overweight or obese children has increased from 20.9% in 1995; a nearly 5% growth (Australian Bureau of Statistics, 2013).



The costs
There are many health complications associated with childhood weight issues, including immediate and longer-term health consequences in children, and especially adolescents. These range from orthopaedic complications, sleep apnoea and liver issues to the more common problems of cardiovascular disease risk factors, type 2 diabetes and psychosocial problems such as low self-esteem and depression (Gill et al., 2009). There are also the problems associated with the likely progression of obesity into adulthood, leading to earlier development of chronic diseases such as type 2 diabetes (Gill et al., 2009). Obesity not only has significant health and social impacts, but also considerable economic impacts. In 2008, the total annual cost of obesity for both children and adults in Australia, including health system costs, productivity and carers costs, was estimated to be around $58 billion (Access Economics, 2008).

The importance of early intervention
Studies have shown that once children become obese they are more likely to stay obese into adulthood and have an increased risk of developing both short and long-term health conditions, such as Type 2 diabetes and cardiovascular disease (Australian Institute of Health and Welfare, 2004). Early onset of such disorders increases the likelihood of early morbidity and mortality making early intervention to prevent the onset of overweight and obesity in children critical (Kelsey, Zaepfel, Bjornstad & Nadeau, 2014).

Early and middle childhood
Young children have limited control over their diets and kilojoule intake. Thus the majority of causes of childhood obesity can be linked to parental influences. During early and middle childhood, parents provide food environments for their children's early experiences with eating (Birch & Davison, 2001). These family environments create the development of food preferences, food consumption patterns, eating styles, and the development of physical activity preferences and patterns that shape the child's continuing weight status (Birch & Davison, 2001).

Role of the family
A parent’s eating behaviours and their parenting practices influence the development of children's eating behaviors, often causing familial weight patterns (Brown & Ogden, 2004). In particular, overweight parents who have problems controlling their own food intake or who are concerned about their children's risk of gaining weight, may adopt controlling child-feeding practices in an attempt to prevent weight gain in their children (Brown & Ogden, 2004). Unfortunately, research reveals that this attempt to control the child's diet may combine with genetic predispositions to promote the development of problematic eating styles and childhood weight gain (Brown & Ogden, 2004). Instead, a positive healthy parental role model may be a better method for improving a child’s diet than attempts at dietary control and restrictions (Brown & Ogden, 2004).

Changing the family environment


The first step to motivating change in the family environment is to ensure that parents realise that unhealthy weight gain is a health risk and not just an aesthetic concern (Ward-Begnoche & Speaker, 2006). Parents also need the tools and motivation to foster healthy family environments for their children. The primary motivation for parents to become involved in their child’s health appears to be a belief that their actions will improve their children’s learning and well-being and that children both want and expect their parent's involvement (Hoover-Dempsey, Bassler & Brissie, 1992; Green, Walker, Hoover-Dempsey & Sandler, 2007). Similarly, recent studies show that children who are motivated to lose weight because of family influences may be more highly engaged in treatment and lose more weight as compared to children who are less motivated by family and social reasons (Braden, Crow & Boutelle, 2014). Parents' need to be aware of both their own problematic lifestyle decisions and how their children’s health can be enhanced by parental engagement in health activities (Green et al., 2007). Therefore a primary public health goal in Australia should be the development of family-based prevention programs to combat childhood weight problems.

Effective prevention programs must focus on providing parents with the information to encourage patterns of preference and selection of healthy food in children as well as promoting a child’s ability to self-regulate food intake (Birch & Davison, 2001). Easily applicable information regarding appropriate portion sizes for children, as well as the timing and frequency of snack and meals, need to be made clear to parents. Furthermore, parents need to understand the dangers of, and be given alternatives to, restricting food and pressuring children to eat (Birch & Davison, 2001). Finally, to be a positive role model in their child’s weight loss journey, parents will generally need to take their own steps towards a healthier lifestyle (Birch & Davison, 2001). To do this, parents need to engage in positive physical activity with their child.

Family based physical activity
Physical activity will be adopted into a lifestyle if it is regarded as enjoyable and if the child, adolescent, or adult is intrinsically motivated to pursue it. Family-based physical activity should typically result in enjoyable and intrinsically motivating physical activity experiences. Such activities could include family football games, bike rides, nature walks, rock climbing, playground visits and trips to the pool depending on the interests and abilities of the family members. These activities remove the emphasis of the activity away from burning kilojoules and concentrate on being active whilst having fun.

Self determination theory
Intrinsic motivation is crucial in terms of understanding why children participate in exercise. A widely used theoretical perspective for understanding intrinsic motivation in physical activity is self-determination theory (Deci & Ryan, 2000). Self-determination theory proposes that intrinsic motivation is typically experienced when individuals feel three characteristics:
 * competence at the activity;
 * autonomy or personal control during the activity;
 * a strong sense of connection, or relatedness, with others when engaging in the activity (Brustad, 2010).

These three characteristics are held to have intrinsic value to the self and are essential for psychological health and behavioral persistence (Deci & Ryan, 2000). Recent research suggests that if individuals are fully committed to weight loss-related behavioral goals and feel not just competent but also autonomous about reaching them, their efforts are more likely to result in long-lasting behaviour change and weight loss (Teixeira, Silva, Mata, Palmeira & Markland, 2012). In contrast, when individuals do not experience any or all of these three essential characteristics (competence, autonomy, and relatedness), they are unlikely to be motivated to participate or motivated merely by extrinsic reasons, such as tangible rewards, and will not persist when such extrinsic incentives are removed (Brustad, 2010). According to self determination theory, parents not only need to enjoy the physical activity but they also need to promote intrinsic motivation in their child to ensure the child adopts exercise into their life.

The question then becomes, how can parents promote intrinsic motivation within their child?

Promoting intrinsic motivation


The majority of people who have observed a child can see that children seem to have an innate desire to move and be active (Alderman, Beighle & Pangrazi, 2006). Similarly, one of the many reasons children enjoy participating in physical activity is the enjoyment they get from interacting with their peers (Weiss & Ferrer-Caja, 2002). The inner enjoyment children feel when being active alone or with their peers is known as intrinsic motivation, and children who are intrinsically motivated to exercise are more likely to perceive their physical activity experiences as positive (Weiss, 2000).

To promote intrinsic motivation students need to be given freedom to make choices during exercise activities (Weiss, 2000). Students who are given more than one activity option are more likely to be motivated than those students who are forced to perform only one activity (Alderman, et al., 2006). This choice does not need to be overly complex or different, it could be as simple as the option of performing different passing types during a basketball activity. It is important to remember that mastering the skill is not the imperative aim of the activity but rather the importance should be on the creation of a safe and encouraging environment for the child (Weiss, 2000).

Enhancing perceived physical competence
Often a child will only be willing to participate in physical activity if s/he deems him/herself competent enough to undertake it (Alderman et al., 2006). Children will often develop negative feelings towards exercise if they are not given appropriate time to learn and practice a skill until they perceive themselves as physical competent. To enhance perceived physical competence children need to be given adequate time to practice skills with a focus on the quality of the movement over the quantity of exercise performed (Alderman et al., 2006). The instructors need to provide positive feedback that emphasises personal improvement such as ‘I am impressed by the way you stretched your arm to catch that ball’ rather than ‘good catch’ (Alderman et al., 2006). When forming groups, instructors need to avoid allowing children to choose their own groups based on peer comparison. This is particularly important in school and sporting groups as it can reduce the anxiety associated with physical exercise if children do not feel they are being compared to their peers (Alderman et al., 2006). Researchers have devised 10 commandments by which parents can maximise motivation for physical activity amongst children whilst minimising negative associations the child may have (see Table 1). By reducing the social fears and anxieties created by physical activity, children are more likely to find enjoyment and make positive associations with exercise.

Case study: Tyler
Tyler is a 9 year old boy who has a BMI of 26, placing him in the overweight range for his age. Tyler loves watching and following the AFL but is too shy to join his local club because he has never played before. Tyler’s parents both have weight issues and are restrictive and controlling over Tyler’s diet. Tyler often sneaks food from the kitchen and has episodes of binging when he is away from his parent’s supervision.
 * How can Tyler’s parents encourage intrinsic motivation and increase Tyler’s perceived physical competence in order to promote exercise?
 * What strategies do Tyler’s parents need to employ regarding their dieting practices to help Tyler view food differently?

Adolescence
From around 13 years of age children begin to take control of their own diet and food choices as an individual, separate from the influence of their parents. Although parents still play a large role through the maintenance of family environments, weight loss intervention during adolescence deviates away from parental influence and towards the individual’s choices. An adolescent’s weight and self-image often reflects a number of influences including peers, media and family. The pressure to remain thin in order to fit in with peers often outweighs the desire to be fit and healthy.

Adolescence is a formative time for lifelong exercise and eating behaviours. The pressures of adolescence often result in dysfunctional eating behaviours, contributing greatly to weight issues (Braet, Claus, Goossens, Moens, Van Vlierberghe & Soetens, 2008). Dysfunctional eating behaviours include: Overweight children are more likely to have dysfunctional eating behaviors compared to normal weight children (Birch, Fisher & Davison, 2003). High levels of external and emotional eating are, in the long term, associated with a decreased responsiveness to internal hunger and satiety (Braet & van Strien, 1997).
 * external eating: eating in response to external food-cues, such as the sight and smell of food, regardless of the internal state of hunger and satiety;
 * emotional eating: eating in response to emotions, usually negative;
 * dietary restraint: cognitive determination and efforts to restrict food intake in order to control body weight (Ho et al., 2013).

Peer pressure
Teenage girls are often strongly influenced by their friendship circles (Paxton, Schutz, Wertheim & Muir, 1999). Studies show that female friendship groups high in body image concerns and dieting, created a subculture during high school that was highly preoccupied by body weight and image (Paxton et al, 1999). Friendship attitudes contribute significantly to the prediction of individual body image concern and eating behaviors amongst teenage girls (Paxton et al, 1999). As friendships play an influential role in an adolescent’s life they can also be used to encourage the importance of healthy lifestyles and motivate teenagers to lose weight. There has been a recent focus on motivating teenagers in peer groups through the use of technology.

Technology
Recent studies using technology such as phone applications, have shown how collecting, sharing and comparing personal fitness information positively impacts activity level and health awareness amongst adolescents (Toscos, Faber, Shnying & Mona, 2006). When properly accommodated to the three cognitions underlying an individual’s behaviour; behavioural regulation, motives, and self-efficacy, tailored interventions can encourage behaviour change (Lacroix, Saini & Goris, 2009). In order to enhance the persuasive power of technology-based physical activity interventions, programs should be tailored to accommodate these underlying cognitions (Lacroix et al., 2009). To target teenage girls, peer pressure and technology need to be combined in a way that targets these cognitions in order to increase physical activity (Lacroix et al., 2009). A study showing the effectiveness of this idea created a micro-blogging site for four friends to engage in friendly competition tracking walking statistics (Young, 2010). Automated text messages were sent to the group members keeping them up to date on the groups progress as well as encouraging their exercise (Young, 2010). Due to the teenagers desire to stay connected to friends as well as their competitive nature the girls all made progress over the four week study (Young, 2010). The girls were excited and motivated to exercise as the focus of the program shifted away from losing weight and instead on achieving goals with friends (Young, 2010).

External eating
Overweight adolescent boys reportedly engage in more external eating than teenagers of a healthy weight (Braet et al., 2008). External eating is often a result of an increasingly sedentary lifestyle, where teenage boys spend hours playing video games or watching television whilst snacking on junk food. This means external eaters do not pay attention to portion control and often consume foods with high sugar content. Studies of teenagers who have successfully lost weight showed that they are more likely to report using healthful weight control behaviors such as watching less television and videos per week than their overweight counterparts (Boutelle, Libbey, Neumark-Sztainer & Story, 2009). However there are a number of issues that prevent teenagers from attempting to change their dysfunctional behaviours.

Obese teenagers are physiologically different from those of normal weight and they also demonstrate significant emotional differences (Sothern et al., 1999). For these teenagers, lack of motivation to exercise has also been attributed, in part, to the idea of ‘learned helplessness’. Learned helplessness theories suggest that people avoid situations where they feel helpless and develop personality deficiencies as result (Sothern, 2014). Learned helplessness deficiencies include passivity, non-assertiveness, inability to see alternatives, sadness, lowered self-esteem and lack of persistence and initiative (McWhorter, Wallmann & Alpert, 2003). As a result of this helplessness, obese teenagers are unwilling to participate in physical activity and often continue with their unhealthy sedentary behaviour.

Social cognitive theory
Social cognitive theory suggests that people are motivated to exercise if they believe that such behavior will benefit them (outcome expectancy) and if they believe that the intended behavior is attainable (self-efficacy) (McWhorter et al., 2003). Social cognitive theory suggests that behaviour is driven by the idea of forethought and therefore goal setting is imperative to behaviour change (Sothern, 2014). This theory can be used to help motivate teenage boys to lose weight through the use of goal setting and rewarding achievements. Successful goals need to be short term, achievable and recordable and should focus on positive activity rather than restrictive measures. For example a teenage boy could have the weekly goal of half an hour more exercise a day, rather than half an hour less television. Each day needs to be recorded and all activities should be able to be self-monitored to maximise a successful outcome. Goal setting is a proven strategy to improve self-efficacy and increased self-efficacy is strongly correlated with determination, a trait essential to weight loss (Sothern, 2014). Following the SMART guidelines (in Table 2) for goal setting will help motivate teenagers to successfully maintain a healthy lifestyle.

Case study: Julie
Julie is a 15 year old girl who is struggling with her weight and is continually dieting. Julie follows diet fads to fit in with her peers. She enjoys spending time on social media sites as well as hanging out with her friends during the afternoons.


 * How can Julie’s peers play a role in motivating Julie to become active?


 * Julie believes there is no point in exercising as she is hopeless at all physical activities. How can her parents help her to realise the importance of participating in exercise and healthy eating?

Conclusion
Motivation plays a key role in helping children maintain a healthy weight and lifestyle. There are now more overweight and obese children in Australia than ever before. It is important that there is a social push towards motivating Australian children to lose weight through healthy eating and physical activity. Age, gender and personality all play a role in the effect motivation has on overweight children. Children under the age of 12 years are generally unable to fully control their own diets. To motivate younger children, adults need to recognise their own contributing behaviour and ensure a healthy family environment is established. Both parents and children need to feel intrinsically motivated to lead a healthy lifestyle as explored through self determination theory.

Adolescence is a time of overwhelming social and physical change and teenagers begin to eat as individuals. Dysfunctional eating behaviours are formed during this time so early intervention is imperative to prevent teenage overweight. Adolescents need a different approach to motivation than younger children and are affected by influences such as technology and peer pressure. Social cognitive theory and the concept of ‘learned helplessness’ explain the behaviour of unmotivated teenagers as well as proposing the importance of goal setting in order to lose weight. Such theories show the importance of understanding motivation and the role it plays in maintaining a healthy lifestyle.

Links

 * Australian Institute of Health and Welfare
 * World Health Organisation